Provider Demographics
NPI:1306037882
Name:WESLEY OPTOMETRY PC
Entity Type:Organization
Organization Name:WESLEY OPTOMETRY PC
Other - Org Name:WESLEY EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:205-221-7779
Mailing Address - Street 1:302 OAKHILL RD
Mailing Address - Street 2:205 OAKHILL RD
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-7465
Mailing Address - Country:US
Mailing Address - Phone:205-221-7779
Mailing Address - Fax:205-221-8749
Practice Address - Street 1:302 OAKHILL RD
Practice Address - Street 2:205 OAKHILL RD
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35504-7465
Practice Address - Country:US
Practice Address - Phone:205-221-7779
Practice Address - Fax:205-221-8749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS785TA265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTAX IDENTIFIER
AL=========OtherTAX IDENTIFIER
K034Medicare PIN
DB9659Medicare PIN