Provider Demographics
NPI:1003935487
Name:STACEY L. WILDA, O.D., P.C.
Entity Type:Organization
Organization Name:STACEY L. WILDA, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:WILDA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-336-0777
Mailing Address - Street 1:415 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-6407
Mailing Address - Country:US
Mailing Address - Phone:580-336-0777
Mailing Address - Fax:580-336-0888
Practice Address - Street 1:415 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-6407
Practice Address - Country:US
Practice Address - Phone:580-336-0777
Practice Address - Fax:580-336-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5119870001Medicare NSC
OK800522432Medicare PIN