Provider Demographics
NPI:1376541714
Name:WILKEN, PAUL W (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:WILKEN
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 1:119 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-1023
Mailing Address - Country:US
Mailing Address - Phone:419-586-5149
Mailing Address - Fax:419-586-3122
Practice Address - Street 1:119 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1023
Practice Address - Country:US
Practice Address - Phone:419-586-5149
Practice Address - Fax:419-586-3122
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2012-01-10
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
OH3317152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0496897Medicaid
OH0180860002Medicare NSC
OHT47587Medicare UPIN
OH0496897Medicaid