Healthcare Provider Details

I. General information

NPI: 1265424188
Provider Name (Legal Business Name): KIRSTEN REED WILGERS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 WILLIAMSON BLVD SUITE 106
PORT ORANGE FL
32128-6100
US

IV. Provider business mailing address

5820 S WILLIAMSON BLVD STE 106
PORT ORANGE FL
32128-6400
US

V. Phone/Fax

Practice location:
  • Phone: 386-767-4449
  • Fax: 386-767-1980
Mailing address:
  • Phone: 386-767-4449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: