Provider Demographics
NPI:1952399859
Name:WILSON, DAVID MEL (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MEL
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 1:4801 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2264
Mailing Address - Country:US
Mailing Address - Phone:765-288-7744
Mailing Address - Fax:765-282-0741
Practice Address - Street 1:4801 W BETHEL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304
Practice Address - Country:US
Practice Address - Phone:765-288-7744
Practice Address - Fax:765-282-0741
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001693B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100153280AMedicaid
0183090001OtherDMERC
0183090001OtherDMERC
IN100153280AMedicaid