Provider Demographics
NPI:1578555447
Name:WILDA, STACEY (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:WILDA
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 1:415 N 7TH ST
Mailing Address - Street 2:PO BOX 815
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-6407
Mailing Address - Country:US
Mailing Address - Phone:580-336-0777
Mailing Address - Fax:580-336-0888
Practice Address - Street 1:415 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-6407
Practice Address - Country:US
Practice Address - Phone:580-336-0777
Practice Address - Fax:580-336-0888
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200035140AMedicaid
OK248512503Medicare PIN