Provider Demographics
NPI:1588608822
Name:PAUL T WILSON OD PC
Entity type:Organization
Organization Name:PAUL T WILSON OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:520-836-9606
Mailing Address - Street 1:653 E COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-2023
Mailing Address - Country:US
Mailing Address - Phone:520-836-9606
Mailing Address - Fax:520-836-3964
Practice Address - Street 1:653 E COTTONWOOD LN
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2023
Practice Address - Country:US
Practice Address - Phone:520-836-9606
Practice Address - Fax:520-836-3964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ256152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0367460001Medicare NSC
0000PFDMLMedicare ID - Type Unspecified
T76717Medicare UPIN
AZZWDCDP01Medicare PIN
AZZWDCDPMedicare PIN