Provider Demographics
NPI:1699702175
Name:WILSON, KAMRIAN SUE (OD)
Entity type:Individual
Prefix:DR
First Name:KAMRIAN
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 MISSOURI AVE.
Mailing Address - Street 2:SUITE 22
Mailing Address - City:ST. ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-4680
Mailing Address - Country:US
Mailing Address - Phone:573-336-4670
Mailing Address - Fax:573-336-5968
Practice Address - Street 1:690 MISSOURI AVE.
Practice Address - Street 2:SUITE 22
Practice Address - City:ST. ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584
Practice Address - Country:US
Practice Address - Phone:573-336-4670
Practice Address - Fax:573-336-5968
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3060152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO313540411Medicaid
MO313540411MOMedicaid
MOU34724Medicare UPIN
MO$$$$$$$$$Medicare Oscar/Certification