Healthcare Provider Details

I. General information

NPI: 1356280143
Provider Name (Legal Business Name): SAMUEL WILCOX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 KINGSRIDGE DR
DAYTON OH
45458-1616
US

IV. Provider business mailing address

8800 KINGSRIDGE DR
DAYTON OH
45458-1616
US

V. Phone/Fax

Practice location:
  • Phone: 937-436-3472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.017978-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: