Provider Demographics
NPI:1518483619
Name:WILGENBUSCH, CASEY JOHN (OD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:JOHN
Last Name:WILGENBUSCH
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 1:2841 BARGEMASTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-8738
Mailing Address - Country:US
Mailing Address - Phone:563-542-6500
Mailing Address - Fax:
Practice Address - Street 1:CMR 402 BOX 613
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-1007
Practice Address - Country:US
Practice Address - Phone:314-590-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist