1235138876 NPI number — DR. DOUGLAS J WILSON OD

Table of content: DR. DOUGLAS J WILSON OD (NPI 1235138876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235138876 NPI number — DR. DOUGLAS J WILSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
DOUGLAS
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235138876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 W GREEN MEADOWS DR
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46140-3204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-477-3937
Provider Business Mailing Address Fax Number:
317-477-3939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 W GREEN MEADOWS DR
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46140-3204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-477-3937
Provider Business Practice Location Address Fax Number:
317-477-3939
Provider Enumeration Date:
07/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18002895A/B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 18002895A/B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000176992 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 410043699 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: JARTL . This is a "EYEFINITY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: IN2895 . This is a "EYEMED" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200280210A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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