Provider Demographics
NPI:1063491660
Name:WILSON, BRENT J (OD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:J
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 1:2580 N LITCHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2071
Mailing Address - Country:US
Mailing Address - Phone:623-932-2020
Mailing Address - Fax:623-932-2668
Practice Address - Street 1:2580 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2071
Practice Address - Country:US
Practice Address - Phone:623-932-2020
Practice Address - Fax:623-932-2668
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU93431Medicare UPIN
AZZ72231Medicare PIN
AZ4157680001Medicare NSC