Provider Demographics
NPI:1659361087
Name:WILD, ANN LYNNE (OD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:LYNNE
Last Name:WILD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2746 LONGMIRE DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5424
Mailing Address - Country:US
Mailing Address - Phone:979-764-1554
Mailing Address - Fax:979-694-2259
Practice Address - Street 1:2746 LONGMIRE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5424
Practice Address - Country:US
Practice Address - Phone:979-764-1554
Practice Address - Fax:979-694-2259
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2142TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E14AMedicare ID - Type Unspecified
TXT16623Medicare UPIN
TX0506160001Medicare NSC