Provider Demographics
NPI:1083140966
Name:WILSON, MICHAEL KENTON (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENTON
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:250 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-1710
Mailing Address - Country:US
Mailing Address - Phone:618-327-3231
Mailing Address - Fax:618-327-8748
Practice Address - Street 1:250 E ELM ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1710
Practice Address - Country:US
Practice Address - Phone:618-327-3231
Practice Address - Fax:618-327-8748
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist