Provider Demographics
NPI:1093702748
Name:WILKINSON, LARRY (O D)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 AVENUE I
Mailing Address - Street 2:P O BOX 607
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-3904
Mailing Address - Country:US
Mailing Address - Phone:281-342-4664
Mailing Address - Fax:281-232-0894
Practice Address - Street 1:4000 AVENUE I
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-3904
Practice Address - Country:US
Practice Address - Phone:281-342-4664
Practice Address - Fax:281-232-0894
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-28
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02165T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019274201Medicaid
TX093539701Medicaid
614328Medicare PIN
TX019274201Medicaid
TXT16629Medicare UPIN