Provider Demographics
NPI:1164523643
Name:WILSON, NATHAN MICHAEL (OD)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:MICHAEL
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 1:10669 MELODY DR
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80234-4113
Mailing Address - Country:US
Mailing Address - Phone:303-452-9312
Mailing Address - Fax:303-452-3515
Practice Address - Street 1:10669 MELODY DR
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4113
Practice Address - Country:US
Practice Address - Phone:303-452-9312
Practice Address - Fax:303-452-3515
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist