Provider Demographics
NPI:1093859563
Name:WILSON, SIDNEY MAURICE (OD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:MAURICE
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6745 S SIWELL RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-8700
Mailing Address - Country:US
Mailing Address - Phone:601-373-0354
Mailing Address - Fax:601-373-0321
Practice Address - Street 1:6745 S SIWELL RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-8700
Practice Address - Country:US
Practice Address - Phone:601-373-0354
Practice Address - Fax:601-373-0321
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS568152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02229351Medicaid
MS02229351Medicaid
MST85037Medicare UPIN