Provider Demographics
NPI:1205510286
Name:WILSON, RILEY JANE (OD)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:JANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47220-1900
Mailing Address - Country:US
Mailing Address - Phone:812-569-3149
Mailing Address - Fax:
Practice Address - Street 1:707 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2157
Practice Address - Country:US
Practice Address - Phone:812-524-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004406A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist