=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003935487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACEY L. WILDA, O.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 12/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 N 7TH ST
-----------------------------------------------------
City | PERRY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73077-6407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-336-0777
-----------------------------------------------------
Fax | 580-336-0888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 N 7TH ST
-----------------------------------------------------
City | PERRY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73077-6407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-336-0777
-----------------------------------------------------
Fax | 580-336-0888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER OPTOMETRIST
-----------------------------------------------------
Name | DR. STACEY LYN WILDA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 580-336-0777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2236
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------