Provider Demographics
NPI:1720073968
Name:WILSON, THOMAS A (OD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
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 1:850 NEWGATE CT
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-2832
Mailing Address - Country:US
Mailing Address - Phone:719-651-4014
Mailing Address - Fax:
Practice Address - Street 1:5482 ESCONDIDO DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1911
Practice Address - Country:US
Practice Address - Phone:719-651-4014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1380152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08013807Medicaid
CO08013807Medicaid
CO6712750001Medicare NSC
COCF2033Medicare PIN
T60880Medicare UPIN