Provider Demographics
NPI:1760477731
Name:WILSON, JON PRESTON (OD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:PRESTON
Last Name:WILSON
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 1:165 W 200 N
Mailing Address - Street 2:71-7
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2834
Mailing Address - Country:US
Mailing Address - Phone:435-722-2981
Mailing Address - Fax:435-722-3732
Practice Address - Street 1:165 W 200 N
Practice Address - Street 2:71-7
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2834
Practice Address - Country:US
Practice Address - Phone:435-722-2981
Practice Address - Fax:435-722-3732
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4944063-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT49440639900001OtherBCBS
UT49440639900001OtherVALUCARE
UT1015OtherOPTICARE
67467OtherPEHP
UT000012521OtherMEDICARE LEGACY NUMBER
870444057OtherVSP
87041538400001OtherNTCA
UT4063OtherEYEMED
UT4063OtherEYEMED