Provider Demographics
NPI:1013924364
Name:WILSON, KENT A (OD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:A
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 1:808 W MOORE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-3002
Mailing Address - Country:US
Mailing Address - Phone:972-563-5533
Mailing Address - Fax:972-524-8489
Practice Address - Street 1:808 W MOORE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-3002
Practice Address - Country:US
Practice Address - Phone:972-563-5533
Practice Address - Fax:972-524-8489
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4572TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
80770QOtherBLUE CROSS BLUE SHIELD
80770QOtherBLUE CROSS BLUE SHIELD
8A2817Medicare ID - Type Unspecified