Provider Demographics
NPI:1669755575
Name:WILSON EYECARE PROFESSIONALS PC
Entity type:Organization
Organization Name:WILSON EYECARE PROFESSIONALS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-477-3937
Mailing Address - Street 1:400 W GREEN MEADOWS DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-3204
Mailing Address - Country:US
Mailing Address - Phone:317-477-3937
Mailing Address - Fax:317-477-3939
Practice Address - Street 1:400 W GREEN MEADOWS DR
Practice Address - Street 2:SUITE 108
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-3204
Practice Address - Country:US
Practice Address - Phone:317-477-3937
Practice Address - Fax:317-477-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002895AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000176992OtherANTHEM BLUE CROSS AND BLUE SHIELD
INJARTLOtherVSP
ININ2895OtherEYEMED
IN200280210Medicaid
IN6603530001Medicare NSC
INM400057292Medicare PIN
IN200280210Medicaid