Provider Demographics
NPI:1619262516
Name:WILCOX, DEBRA (LO)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 N FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1808
Mailing Address - Country:US
Mailing Address - Phone:860-395-7611
Mailing Address - Fax:
Practice Address - Street 1:120 COMMERCIAL PKWY
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2537
Practice Address - Country:US
Practice Address - Phone:203-483-1876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001653156FX1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric Technician