MEDICARE: AUBREY LINN WILSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2018021081	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457847451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUBREY LINN WILSON O.D.

Provider Business Mailing Address
First Line	:	118 CASS AVE
Second Line	:
City	:	MOUNT CLEMENS
State	:	MI
Zip	:	48043-2204
Country	:	US
Telephone Number	:	586-468-7370
Fax Number	:

Provider Business Practice Location Address
First Line	:	8212 N LINDBERGH BLVD
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63031-7107
Country	:	US
Telephone Number	:	314-831-2221
Fax Number	:	314-831-0199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2018
Last Update Date	:	11/19/2019

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