Provider Demographics
NPI:1457847451
Name:WILSON, AUBREY LINN (OD)
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:LINN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:
Practice Address - Street 1:8212 N LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7107
Practice Address - Country:US
Practice Address - Phone:314-831-2221
Practice Address - Fax:314-831-0199
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018021081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194879023Medicaid