Provider Demographics
NPI:1538265178
Name:WILSON, STEVEN C (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:C
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 1:126 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3104
Mailing Address - Country:US
Mailing Address - Phone:304-235-2020
Mailing Address - Fax:304-235-8665
Practice Address - Street 1:126 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3104
Practice Address - Country:US
Practice Address - Phone:304-235-2020
Practice Address - Fax:304-235-8665
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV758OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149994000Medicaid
WV223408OtherCARELINK
WV5624220OtherAETNA
WV5003820001OtherDMERC
WV1023416OtherBRICKSTREET
WV1495201OtherUMWA
WV5003820001OtherDMERC
WVWI0596721Medicare ID - Type Unspecified