MEDICARE: DENISE WILSON O D P C

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	4901002778	MI

General Provider Information

NPI Number	:	1306921192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENISE WILSON O D P C

Provider Business Mailing Address
First Line	:	3271 UNION LAKE RD
Second Line	:
City	:	COMMERCE TWP
State	:	MI
Zip	:	48382-4550
Country	:	US
Telephone Number	:	248-360-0121
Fax Number	:

Provider Business Practice Location Address
First Line	:	3271 UNION LAKE RD
Second Line	:
City	:	COMMERCE TWP
State	:	MI
Zip	:	48382-4550
Country	:	US
Telephone Number	:	248-360-0121
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUDITH DENISE WILSON
Credential	:	O.D.
Telephone Number	:	248-360-0121

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	05/19/2011

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