Provider Demographics
NPI:1508207309
Name:WILSON, KYLE DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:DOUGLAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:158 INVERNESS DR W
Mailing Address - Street 2:A309
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-5026
Mailing Address - Country:US
Mailing Address - Phone:801-473-9002
Mailing Address - Fax:
Practice Address - Street 1:61 WESTFARMS MALL
Practice Address - Street 2:D111
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2631
Practice Address - Country:US
Practice Address - Phone:801-473-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8674334-9934152W00000X
CT2897152W00000X
CO3124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist