Provider Demographics
NPI:1700602174
Name:WILSON, TYRONE ERVIN
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:ERVIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 GALLIVAN BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3190
Mailing Address - Country:US
Mailing Address - Phone:857-406-9883
Mailing Address - Fax:
Practice Address - Street 1:98 DAKOTA ST APT 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1270
Practice Address - Country:US
Practice Address - Phone:857-406-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6629156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician