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General NPI Number Information
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NPI Number | 1215923420
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Entity Type | Individual
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Provider Name | GREGORY LUIS WILSON O.D.
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Gender | Male
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Dates
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Enumeration Date | 09/22/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1055 TEKULVE RD
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City | BATESVILLE
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State | IN
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Zip | 47006-8979
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Country | US
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Telephone | 812-934-5347
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Fax | 812-932-2020
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Provider Business Mailing Address
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Address Line | 1055 TEKULVE RD
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City | BATESVILLE
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State | IN
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Zip | 47006-8979
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Country | US
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Telephone | 812-934-5347
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Fax | 812-932-2020
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | IN18002615
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License Number State | IN
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