Provider Demographics
NPI:1235138876
Name:WILSON, DOUGLAS J (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
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 1:400 W GREEN MEADOWS DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-3204
Mailing Address - Country:US
Mailing Address - Phone:317-477-3937
Mailing Address - Fax:317-477-3939
Practice Address - Street 1:400 W GREEN MEADOWS DR
Practice Address - Street 2:SUITE 108
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-3204
Practice Address - Country:US
Practice Address - Phone:317-477-3937
Practice Address - Fax:317-477-3939
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002895A/B152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000176992OtherBCBS
IN410043699OtherRAILROAD MEDICARE
INJARTLOtherEYEFINITY
ININ2895OtherEYEMED
IN200280210AMedicaid
INJARTLOtherEYEFINITY
IN6603530001Medicare NSC
INM100057291Medicare PIN