Provider Demographics
NPI:1265435283
Name:WILCOX, PETER EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:EDWARD
Last Name:WILCOX
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 1:2652 GEORGE WASHINGTON MEMORIAL HWY
Mailing Address - Street 2:STE 1
Mailing Address - City:HAYES
Mailing Address - State:VA
Mailing Address - Zip Code:23072-3464
Mailing Address - Country:US
Mailing Address - Phone:804-642-9800
Mailing Address - Fax:804-624-0334
Practice Address - Street 1:2652 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:STE 1
Practice Address - City:HAYES
Practice Address - State:VA
Practice Address - Zip Code:23072-3464
Practice Address - Country:US
Practice Address - Phone:804-642-9800
Practice Address - Fax:804-642-0334
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2012-08-20
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
VA0618000147152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
1250960001OtherMEDICARE DMERC
VA92-3438-1Medicaid
410001099Medicare PIN
1250960001OtherMEDICARE DMERC