Provider Demographics
NPI:1184629818
Name:MOAK, WILSON E (MD)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:E
Last Name:MOAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:1190 N STATE ST
Mailing Address - Street 2:STE 403
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2413
Mailing Address - Country:US
Mailing Address - Phone:601-353-2020
Mailing Address - Fax:601-714-5110
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:STE 403
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-353-2020
Practice Address - Fax:601-714-5110
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06305207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013075Medicaid
MSB65904Medicare UPIN
MS180000329Medicare ID - Type UnspecifiedMEDICARE
MS00013075Medicaid