Provider Demographics
NPI:1669070041
Name:WILSON, JOSEPH WADE (OD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:WADE
Last Name:WILSON
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 1:4279 COUNTY HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-8401
Mailing Address - Country:US
Mailing Address - Phone:270-427-1133
Mailing Address - Fax:
Practice Address - Street 1:22 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-7478
Practice Address - Country:US
Practice Address - Phone:270-487-5741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2207DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist