Provider Demographics
NPI:1497337091
Name:WILSON, MADDISON (OD)
Entity Type:Individual
Prefix:DR
First Name:MADDISON
Middle Name:
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 1:131 COLUMBUS BLVD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4243
Mailing Address - Country:US
Mailing Address - Phone:401-486-5491
Mailing Address - Fax:
Practice Address - Street 1:580 SAINT JOHNSBURY RD STE 12
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:NH
Practice Address - Zip Code:03561-3437
Practice Address - Country:US
Practice Address - Phone:603-444-2484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133944152W00000X
NH1044152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist