Provider Demographics
NPI:1700048436
Name:STEVEN C. WILSON, O.D. INC.
Entity Type:Organization
Organization Name:STEVEN C. WILSON, O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-235-2020
Mailing Address - Street 1:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-1637
Mailing Address - Country:US
Mailing Address - Phone:304-235-2020
Mailing Address - Fax:304-235-8665
Practice Address - Street 1:126 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3104
Practice Address - Country:US
Practice Address - Phone:304-235-2020
Practice Address - Fax:304-235-8665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV758OD332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149994000OtherVSP
WV5003820001OtherDMERC
KY5003820001OtherDMERC
WV0149994000OtherVSP