Provider Demographics
NPI:1427011360
Name:WILMOTH, PHILIP MARC (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:MARC
Last Name:WILMOTH
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:PO BOX 2618
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2618
Mailing Address - Country:US
Mailing Address - Phone:304-366-4721
Mailing Address - Fax:304-366-4847
Practice Address - Street 1:709 MORGANTOWN AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-4721
Practice Address - Fax:304-366-4847
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV78700152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV015096400Medicaid
WVWI0588611Medicare ID - Type Unspecified
WV015096400Medicaid