Provider Demographics
NPI:1023104239
Name:WILSON, DONALD ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ROBERT
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 1:88 MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9337
Mailing Address - Country:US
Mailing Address - Phone:585-223-3412
Mailing Address - Fax:
Practice Address - Street 1:117 E UNION ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1503
Practice Address - Country:US
Practice Address - Phone:315-331-7917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000914282002OtherHEALTH NOW
NY00468644Medicaid
NY010003598OtherBLUE CHOICE
NY101949CSOtherPREFERRED CARE
NY020003598OtherBLUE CROSS BLUE SHIELD
NY10476BMedicare ID - Type Unspecified
NY00468644Medicaid