Provider Demographics
NPI:1184727612
Name:WILSON, JEFFREY F (OD PC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:F
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W WHEATLAND AVE
Mailing Address - Street 2:P O BOX 321
Mailing Address - City:REMUS
Mailing Address - State:MI
Mailing Address - Zip Code:49340-0321
Mailing Address - Country:US
Mailing Address - Phone:989-967-8668
Mailing Address - Fax:989-967-3032
Practice Address - Street 1:126 W WHEATLAND AVE
Practice Address - Street 2:
Practice Address - City:REMUS
Practice Address - State:MI
Practice Address - Zip Code:49340
Practice Address - Country:US
Practice Address - Phone:989-967-8668
Practice Address - Fax:989-967-3032
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003093152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4373941Medicaid
MION55020Medicare ID - Type Unspecified
MI4373941Medicaid