Provider Demographics
NPI:1649269218
Name:PHILLIPS, WILBUR EUGENE (OD)
Entity type:Individual
Prefix:DR
First Name:WILBUR
Middle Name:EUGENE
Last Name:PHILLIPS
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 1:13330 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1310
Mailing Address - Country:US
Mailing Address - Phone:734-285-2990
Mailing Address - Fax:734-285-2712
Practice Address - Street 1:13330 EUREKA RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1310
Practice Address - Country:US
Practice Address - Phone:734-285-2990
Practice Address - Fax:734-285-2712
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5006796Medicaid
MI900H24843OtherBLUE CROSS
MIT33769Medicare UPIN
MIN66480002Medicare PIN