Provider Demographics
NPI:1346430238
Name:PEREZ-WILSON, MARISA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:
Last Name:PEREZ-WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:13605 XAVIER LN
Mailing Address - Street 2:SUITE G @ THE CHATEAUX
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-3603
Mailing Address - Country:US
Mailing Address - Phone:303-951-1820
Mailing Address - Fax:303-951-1826
Practice Address - Street 1:13605 XAVIER LN
Practice Address - Street 2:SUITE G @ THE CHATEAUX
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-3603
Practice Address - Country:US
Practice Address - Phone:303-951-1820
Practice Address - Fax:303-951-1826
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2581152W00000X
FL4192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist