Healthcare Provider Details

I. General information

NPI: 1538423769
Provider Name (Legal Business Name): MARK ALAN WILKINS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4702 MID RIVERS MALL DR
COTTLEVILLE MO
63376-2883
US

IV. Provider business mailing address

402 LYNWOOD FOREST DR
MANCHESTER MO
63021-5511
US

V. Phone/Fax

Practice location:
  • Phone: 636-244-5378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2012017715
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: