Provider Demographics
NPI:1215923420
Name:WILSON, GREGORY LUIS (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LUIS
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 1:1055 TEKULVE RD
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47006-8979
Mailing Address - Country:US
Mailing Address - Phone:812-934-5347
Mailing Address - Fax:812-932-2020
Practice Address - Street 1:1055 TEKULVE RD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-8979
Practice Address - Country:US
Practice Address - Phone:812-934-5347
Practice Address - Fax:812-932-2020
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ18002615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000090531OtherANTHEM
IN0953810001OtherDMERC
ININ2615OtherEYEMED
IN02880OtherSPECTERA
IN5083058OtherAETNA
INU20749Medicare UPIN
ININ2615OtherEYEMED