Provider Demographics
NPI:1518074301
Name:WILSON, DOUGLAS R (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 25TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-3007
Mailing Address - Country:US
Mailing Address - Phone:812-375-9390
Mailing Address - Fax:812-375-9394
Practice Address - Street 1:3902 25TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3007
Practice Address - Country:US
Practice Address - Phone:812-375-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045152207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200091450Medicaid
IN4636010001Medicare NSC
144760Medicare PIN
F24076Medicare UPIN