Healthcare Provider Details

I. General information

NPI: 1093859563
Provider Name (Legal Business Name): SIDNEY MAURICE WILSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6745 S SIWELL RD SUITE 106
BYRAM MS
39272-8700
US

IV. Provider business mailing address

6745 S SIWELL RD SUITE 106
BYRAM MS
39272-8700
US

V. Phone/Fax

Practice location:
  • Phone: 601-373-0354
  • Fax: 601-373-0321
Mailing address:
  • Phone: 601-373-0354
  • Fax: 601-373-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number568
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: