Provider Demographics
NPI:1407883895
Name:WILSON, MARK JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
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 1:5015 BELMONT RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1319
Mailing Address - Country:US
Mailing Address - Phone:813-681-1036
Mailing Address - Fax:813-651-0718
Practice Address - Street 1:655 BRANDON TOWN CENTER MALL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4770
Practice Address - Country:US
Practice Address - Phone:813-681-1036
Practice Address - Fax:813-651-0718
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20106ZMedicare ID - Type Unspecified