Provider Demographics
NPI:1639390552
Name:DOUGLAS M. WILSON, O.D., P.C.
Entity Type:Organization
Organization Name:DOUGLAS M. WILSON, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-775-9355
Mailing Address - Street 1:71 ALLEN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4570
Mailing Address - Country:US
Mailing Address - Phone:802-775-9355
Mailing Address - Fax:802-775-4577
Practice Address - Street 1:71 ALLEN ST STE 201
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4570
Practice Address - Country:US
Practice Address - Phone:802-775-9355
Practice Address - Fax:802-775-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000152 VT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006627Medicaid
VT0540360001Medicare NSC
VT0006627Medicaid