Provider Demographics
NPI:1619051141
Name:PERSELL, WESLEY ONEAL (OD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:ONEAL
Last Name:PERSELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7085 HIGHWAY 64 STE 2
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:TN
Mailing Address - Zip Code:38060-3366
Mailing Address - Country:US
Mailing Address - Phone:901-466-1333
Mailing Address - Fax:901-466-1333
Practice Address - Street 1:7085 HIGHWAY 64 STE 2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:TN
Practice Address - Zip Code:38060-3366
Practice Address - Country:US
Practice Address - Phone:901-466-1333
Practice Address - Fax:901-466-1333
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2443152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4126391OtherBC/BS
TN4126391Medicaid