Provider Demographics
NPI:1285859801
Name:WILSON, GLENN L (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:120 W MAIN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-4264
Mailing Address - Country:US
Mailing Address - Phone:972-285-9896
Mailing Address - Fax:972-329-1005
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-4264
Practice Address - Country:US
Practice Address - Phone:972-285-9896
Practice Address - Fax:972-329-1005
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2024-04-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXDR0427156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0879880001Medicare NSC
TX1300790001Medicare NSC