Provider Demographics
NPI:1720207178
Name:WHEELER, DAVID GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLENN
Last Name:WHEELER
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 1:569 MID RIVERS MALL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2152
Mailing Address - Country:US
Mailing Address - Phone:636-970-2020
Mailing Address - Fax:
Practice Address - Street 1:569 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2152
Practice Address - Country:US
Practice Address - Phone:636-970-2020
Practice Address - Fax:636-397-0833
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015042988152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO172200015OtherMEDICARE
MO1720207178Medicaid