Provider Demographics
NPI:1063965515
Name:WILSHIRE, LAURA (OD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WILSHIRE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:SPIKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9754
Practice Address - Street 1:8309 N KNOXVILLE AVE
Practice Address - Street 2:STE. 1
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2170
Practice Address - Country:US
Practice Address - Phone:309-713-3664
Practice Address - Fax:309-693-9754
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-011052152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046011052Medicaid