Provider Demographics
NPI:1407832454
Name:WILSON, RYAN J (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
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 1:112 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1338
Mailing Address - Country:US
Mailing Address - Phone:309-944-5303
Mailing Address - Fax:309-944-3465
Practice Address - Street 1:112 S CENTER ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1338
Practice Address - Country:US
Practice Address - Phone:309-944-5303
Practice Address - Fax:309-944-3465
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009598152W00000X
IA02270152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009598Medicaid
977130OtherIL GROUP MEDICARE
977130OtherIL GROUP MEDICARE
U97441Medicare UPIN