Provider Demographics
NPI:1720261720
Name:WILSON OPTOMETRY PC
Entity Type:Organization
Organization Name:WILSON OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JAMES
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:317-477-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2012-07-19
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
INJARTLOtherVSP
IN200280210Medicaid
IN000000176992OtherANTHEM BLUE CROSS AND BLUE SHIELD
IN410043699OtherMEDICARE RAILROAD
ININ2895OtherEYEMED
INJARTLOtherVSP
IN3921830001Medicare NSC
IN151880Medicare PIN