Provider Demographics
NPI:1225336324
Name:WILES, DEREK B (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:B
Last Name:WILES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:200 E WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:LEADINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63601-4436
Mailing Address - Country:US
Mailing Address - Phone:573-431-1301
Mailing Address - Fax:573-431-9339
Practice Address - Street 1:200 E WOODLAWN DR
Practice Address - Street 2:
Practice Address - City:LEADINGTON
Practice Address - State:MO
Practice Address - Zip Code:63601-4436
Practice Address - Country:US
Practice Address - Phone:573-431-1301
Practice Address - Fax:573-431-9339
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011018570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist