Provider Demographics
NPI:1407931629
Name:WILSON, DAVID RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RUSSELL
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 1:19336 LEITERSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742
Mailing Address - Country:US
Mailing Address - Phone:717-258-4422
Mailing Address - Fax:717-258-4245
Practice Address - Street 1:650 E HIGH ST
Practice Address - Street 2:STE 652
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013
Practice Address - Country:US
Practice Address - Phone:717-258-4422
Practice Address - Fax:717-258-4245
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001476152W00000X
MDTA1894152W00000X
VA0618001399152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011408310002Medicaid
MD64392302OtherCAREFIRST BLUE CROSS BLUE
PAWI1634058OtherHIGHMARK BLUE SHIELD
V00737Medicare UPIN
PA083513P3EMedicare ID - Type Unspecified