Provider Demographics
NPI:1669517306
Name:WILSON, JAMES E (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:E
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 1:10610 PENNSYLVANIA STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280
Mailing Address - Country:US
Mailing Address - Phone:317-844-6269
Mailing Address - Fax:
Practice Address - Street 1:10610 N PENNSYLVANIA ST
Practice Address - Street 2:STE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-2000
Practice Address - Country:US
Practice Address - Phone:317-844-6269
Practice Address - Fax:317-815-7567
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001602152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T98132Medicare UPIN
266650EMedicare ID - Type Unspecified