Provider Demographics
NPI:1285170696
Name:WILSON POLITO PLLC
Entity type:Organization
Organization Name:WILSON POLITO PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-743-5830
Mailing Address - Street 1:1844 W PULLMAN RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4014
Mailing Address - Country:US
Mailing Address - Phone:208-883-1800
Mailing Address - Fax:208-883-1811
Practice Address - Street 1:1844 W PULLMAN RD
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4014
Practice Address - Country:US
Practice Address - Phone:208-883-1800
Practice Address - Fax:208-883-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 100-222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty