Provider Demographics
NPI:1265424188
Name:WILGERS, KIRSTEN REED (OD)
Entity type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:REED
Last Name:WILGERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 S WILLIAMSON BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6400
Mailing Address - Country:US
Mailing Address - Phone:386-767-4449
Mailing Address - Fax:
Practice Address - Street 1:5820 WILLIAMSON BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6100
Practice Address - Country:US
Practice Address - Phone:386-767-4449
Practice Address - Fax:386-767-1980
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620669700Medicaid
FL010470OtherFLORIDA HEALTH CARE
FL542098594OtherVISIONCARE PLANS
FL5021890001OtherDMERC
FL620815100Medicaid
FLFL3622OtherEYEMED
FL010470OtherFLORIDA HEALTH CARE
FL5021890001OtherDMERC
FL620815100Medicaid