Provider Demographics
NPI:1548456312
Name:WILSON, PAUL T (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:T
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 1:653 E COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-2023
Mailing Address - Country:US
Mailing Address - Phone:520-836-9606
Mailing Address - Fax:520-836-3964
Practice Address - Street 1:653 E COTTONWOOD LANE
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122
Practice Address - Country:US
Practice Address - Phone:520-836-9606
Practice Address - Fax:520-836-3964
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ256152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWDCDP01Medicare PIN