Provider Demographics
NPI:1750506671
Name:STEVEN M. WILSON, O.D., P.C.
Entity type:Organization
Organization Name:STEVEN M. WILSON, O.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSWALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-244-3000
Mailing Address - Street 1:PO BOX 3211
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3211
Mailing Address - Country:US
Mailing Address - Phone:229-244-3000
Mailing Address - Fax:229-244-1934
Practice Address - Street 1:2108 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2947
Practice Address - Country:US
Practice Address - Phone:229-244-3000
Practice Address - Fax:229-244-1934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3248Medicare ID - Type Unspecified