Provider Demographics
NPI:1821251422
Name:WILKINSON, JUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:WILKINSON
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 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:8658 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-3839
Practice Address - Country:US
Practice Address - Phone:314-968-4243
Practice Address - Fax:314-968-3273
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009010664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1821251422Medicaid
MOMA5227036Medicare UPIN
MO1821251422Medicaid
MO0360070003Medicare NSC