1265424188 NPI number — DR. KIRSTEN REED WILGERS O.D.

Table of content: DR. KIRSTEN REED WILGERS O.D. (NPI 1265424188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265424188 NPI number — DR. KIRSTEN REED WILGERS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILGERS
Provider First Name:
KIRSTEN
Provider Middle Name:
REED
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1265424188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5820 S WILLIAMSON BLVD
Provider Second Line Business Mailing Address:
STE 106
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32128-6400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-767-4449
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5820 WILLIAMSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32128-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-767-4449
Provider Business Practice Location Address Fax Number:
386-767-1980
Provider Enumeration Date:
08/17/2005

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:  OPC3622 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 620669700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010470 . This is a "FLORIDA HEALTH CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 542098594 . This is a "VISIONCARE PLANS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5021890001 . This is a "DMERC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 620815100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: FL3622 . This is a "EYEMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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