Provider Demographics
NPI:1881738532
Name:WILSON, JONATHAN WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:WILLIAM
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 1:5339 SHETLAND TRL
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-8365
Mailing Address - Country:US
Mailing Address - Phone:901-867-1523
Mailing Address - Fax:
Practice Address - Street 1:1890 GOODMAN RD E STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9504
Practice Address - Country:US
Practice Address - Phone:662-772-5882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS722152W00000X
TN2525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS410000222Medicare ID - Type Unspecified
TNVO2311Medicare UPIN