Provider Demographics
NPI:1235199126
Name:WILSON, DOUGLAS MARK (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MARK
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 1:71 ALLEN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-775-9355
Mailing Address - Fax:802-775-4577
Practice Address - Street 1:71 ALLEN ST
Practice Address - Street 2:STE 201
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-9355
Practice Address - Fax:802-775-4577
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000152152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0576Medicaid
VTDOVT6627Medicare ID - Type Unspecified
VTOVN0576Medicaid