Provider Demographics
NPI:1326008459
Name:WILSON, STEVEN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MICHAEL
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:PO BOX 3211
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3211
Mailing Address - Country:US
Mailing Address - Phone:229-244-3000
Mailing Address - Fax:229-244-1934
Practice Address - Street 1:2108 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2947
Practice Address - Country:US
Practice Address - Phone:229-244-3000
Practice Address - Fax:229-244-1934
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP1564152W00000X
GAOPT000922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00213342AMedicaid
GA00213342AMedicaid
GAU22913Medicare UPIN