Provider Demographics
NPI:1902890858
Name:WILSON, DEXTER E (OD)
Entity Type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:E
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 1:918 DECATHLON DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3441
Mailing Address - Country:US
Mailing Address - Phone:319-236-2020
Mailing Address - Fax:
Practice Address - Street 1:918 DECATHLON DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-3441
Practice Address - Country:US
Practice Address - Phone:319-236-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6146811Medicaid
IAI11273Medicare PIN