Provider Demographics
NPI:1518166297
Name:WILSON, KRISTIN SKLUZACEK (OD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SKLUZACEK
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:SKLUZACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:302 S KNOWLES AVE
Mailing Address - Street 2:PO BOX 119
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1731
Mailing Address - Country:US
Mailing Address - Phone:715-246-2419
Mailing Address - Fax:
Practice Address - Street 1:302 S KNOWLES AVE
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1731
Practice Address - Country:US
Practice Address - Phone:715-246-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009996152W00000X
WI3126152W00000X
MN3137152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009996Medicaid