Provider Demographics
NPI:1689777468
Name:WILKINS, LEONARD (OD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:WILKINS
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 1:209 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3317
Mailing Address - Country:US
Mailing Address - Phone:918-456-0585
Mailing Address - Fax:918-456-6232
Practice Address - Street 1:209 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3317
Practice Address - Country:US
Practice Address - Phone:918-456-0585
Practice Address - Fax:918-456-6232
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK815152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
0676100001OtherDMERC/PIN
156833OtherFED NWO
OK100767470AMedicaid
5001OtherNEFN DISP
OK900243OtherOK. NWO
OKT40715Medicare UPIN
OK541429128Medicare PIN