MEDICARE: JOSEPH WADE WILSON OD

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	2207DT	KY

General Provider Information

NPI Number	:	1669070041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH WADE WILSON OD

Provider Business Mailing Address
First Line	:	4279 COUNTY HOUSE RD
Second Line	:
City	:	TOMPKINSVILLE
State	:	KY
Zip	:	42167-8401
Country	:	US
Telephone Number	:	270-427-1133
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 EXECUTIVE DR
Second Line	:
City	:	TOMPKINSVILLE
State	:	KY
Zip	:	42167-7478
Country	:	US
Telephone Number	:	270-487-5741
Fax Number	:

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

Provider Enumeration Date	:	10/16/2020
Last Update Date	:	05/06/2024

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