Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 152W00000X | Optometrist | | 046-008222 | ILLINOIS | No |
| 2 | 152W00000X | Optometrist | | 046-007815 | ILLINOIS | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | BEDWELL 764090 | MEDICARE PIN | | |
| 2 | WIETIES U21978 | MEDICARE UPIN | | |
| 3 | BEDWELL T38734 | MEDICARE UPIN | | |
| 4 | 0790230001 | MEDICARE NSC | | |
| 5 | WIETIES 76409001 | MEDICARE PIN | | |
| 6 | BEDWELL 046-007815 | MEDICAID | ILLINOIS | |
| 7 | WIETIES 046-008222 | MEDICAID | ILLINOIS | |
| 8 | BEDWELL 0790230001 | OTHER | | PALMETTO GBA |
| 9 | WIETIES P01082010 | OTHER | | PALMETTO GBA |