Provider Demographics
NPI:1992750780
Name:WILEY, MARK EUGENE (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EUGENE
Last Name:WILEY
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:PO BOX 180369
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-0369
Mailing Address - Country:US
Mailing Address - Phone:601-397-0095
Mailing Address - Fax:
Practice Address - Street 1:200 MARKET PL
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-4429
Practice Address - Country:US
Practice Address - Phone:601-420-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00272896Medicaid