Provider Demographics
NPI:1699952036
Name:MICHAEL E WILSON OD PC
Entity type:Organization
Organization Name:MICHAEL E WILSON OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-461-2144
Mailing Address - Street 1:320 N JEFF DAVIS DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1669
Mailing Address - Country:US
Mailing Address - Phone:770-461-2144
Mailing Address - Fax:770-461-5792
Practice Address - Street 1:320 N JEFF DAVIS DR
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1669
Practice Address - Country:US
Practice Address - Phone:770-461-2144
Practice Address - Fax:770-461-5792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0456290001Medicare NSC