Basic Information
| Provider Information | |||||||||
| NPI: | 1891799672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HSIEH | ||||||||
| FirstName: | WING | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4405 HAMILTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511041140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122393937 | ||||||||
| FaxNumber: | 7122394946 | ||||||||
| Practice Location | |||||||||
| Address1: | 4405 HAMILTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511041140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122393937 | ||||||||
| FaxNumber: | 7122394946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 481 | SD | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1894 | IA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 130025300 | 05 | MN | MEDICAID | 9201730 | 05 | SD | MEDICAID | 9280081 | 05 | IA | MEDICAID | 6280081 | 05 | IA | MEDICAID | 8280081 | 05 | IA | MEDICAID | 46044447400 | 05 | NE | MEDICAID | 9201418 | 05 | SD | MEDICAID | 10025032100 | 05 | NE | MEDICAID | 9201419 | 05 | SD | MEDICAID | 9201417 | 05 | SD | MEDICAID | 9201415 | 05 | SD | MEDICAID |