MEDICARE: DR. KIRSTEN REED WILGERS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC3622	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	010470	OTHER	FL	FLORIDA HEALTH CARE
3	542098594	OTHER	FL	VISIONCARE PLANS
4	5021890001	OTHER	FL	DMERC
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	FL3622	OTHER	FL	EYEMED

General Provider Information

NPI Number	:	1265424188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIRSTEN REED WILGERS O.D.

Provider Business Mailing Address
First Line	:	5820 S WILLIAMSON BLVD
Second Line	:	STE 106
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-6400
Country	:	US
Telephone Number	:	386-767-4449
Fax Number	:

Provider Business Practice Location Address
First Line	:	5820 WILLIAMSON BLVD
Second Line	:	SUITE 106
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-6100
Country	:	US
Telephone Number	:	386-767-4449
Fax Number	:	386-767-1980

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	03/29/2017

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