Provider Demographics
NPI:1861661407
Name:GREGORY L. WILSON
Entity Type:Organization
Organization Name:GREGORY L. WILSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-934-5347
Mailing Address - Street 1:1055 TEKULVE RD
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47006-8979
Mailing Address - Country:US
Mailing Address - Phone:812-934-5347
Mailing Address - Fax:812-932-2020
Practice Address - Street 1:1055 TEKULVE RD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-8979
Practice Address - Country:US
Practice Address - Phone:812-934-5347
Practice Address - Fax:812-932-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002615A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0953810001Medicare NSC