Provider Demographics
NPI:1164699054
Name:ROGER L. WILSON, O.D., P.A.
Entity Type:Organization
Organization Name:ROGER L. WILSON, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-280-2021
Mailing Address - Street 1:110 SOLANA RD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2230
Mailing Address - Country:US
Mailing Address - Phone:904-280-2021
Mailing Address - Fax:904-280-2024
Practice Address - Street 1:110 SOLANA RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2230
Practice Address - Country:US
Practice Address - Phone:904-280-2021
Practice Address - Fax:904-280-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-11
Last Update Date:2008-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP2569152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7661Medicare PIN
FLU25956Medicare UPIN