Provider Demographics
NPI:1841236635
Name:WILSON, DIANE G (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:G
Other - Last Name:WERKMEISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:7 HUNTLEIGH WOODS
Mailing Address - Street 2:
Mailing Address - City:BARNHART
Mailing Address - State:MO
Mailing Address - Zip Code:63012-1349
Mailing Address - Country:US
Mailing Address - Phone:636-296-8612
Mailing Address - Fax:636-296-8055
Practice Address - Street 1:1235 WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2142
Practice Address - Country:US
Practice Address - Phone:636-296-8612
Practice Address - Fax:636-296-8055
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02765152W00000X, 152WV0400X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108374OtherBLUE CROSS/BLUE SHIELD
MO22-02076OtherUNITED HEALTHCARE
MO401231OtherGROUP HEALTH PLAN
MO20717OtherBLUE CHOICE
MO20717OtherBLUE CHOICE
MO22-02076OtherUNITED HEALTHCARE