Provider Demographics
NPI:1083291454
Name:WILSON, KELSEY (OD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-1815
Mailing Address - Country:US
Mailing Address - Phone:207-324-8888
Mailing Address - Fax:207-636-5023
Practice Address - Street 1:272 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-1815
Practice Address - Country:US
Practice Address - Phone:207-324-8888
Practice Address - Fax:207-490-1716
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT1044152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist