Provider Demographics
NPI:1063074540
Name:WILZONSKI, JON R (OD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:WILZONSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JON
Other - Middle Name:R
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1235 WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2142
Mailing Address - Country:US
Mailing Address - Phone:636-296-8612
Mailing Address - Fax:636-296-8055
Practice Address - Street 1:1235 WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2142
Practice Address - Country:US
Practice Address - Phone:636-296-8612
Practice Address - Fax:636-296-8055
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021299152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty