Provider Demographics
NPI:1710064142
Name:WILSON, LORNA KATRINA (OD)
Entity Type:Individual
Prefix:DR
First Name:LORNA
Middle Name:KATRINA
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31519 WINTERPLACE PKWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1894
Mailing Address - Country:US
Mailing Address - Phone:410-749-1545
Mailing Address - Fax:410-742-3707
Practice Address - Street 1:4699 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-3159
Practice Address - Country:US
Practice Address - Phone:803-787-3080
Practice Address - Fax:803-738-0070
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9957Medicaid
SCDA9957Medicaid
SC02678213Medicare ID - Type Unspecified