Provider Demographics
NPI:1356643084
Name:ROY A. WILSON, OD, PC
Entity Type:Organization
Organization Name:ROY A. WILSON, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-788-1610
Mailing Address - Street 1:31114 HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-5803
Mailing Address - Country:US
Mailing Address - Phone:248-788-1610
Mailing Address - Fax:248-788-8290
Practice Address - Street 1:31114 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-5803
Practice Address - Country:US
Practice Address - Phone:248-788-1610
Practice Address - Fax:248-788-8290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0182720001Medicare NSC