Provider Demographics
NPI:1992567382
Name:WILSON, GAVIN DAVIS
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:DAVIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-1804
Mailing Address - Country:US
Mailing Address - Phone:423-476-2217
Mailing Address - Fax:423-254-5738
Practice Address - Street 1:913 KEITH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-1804
Practice Address - Country:US
Practice Address - Phone:423-476-2217
Practice Address - Fax:423-254-5738
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3035156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician