Provider Demographics
NPI:1053342253
Name:BATSON, WANDA COOK (OD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:COOK
Last Name:BATSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:JUNE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:207 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3543
Mailing Address - Country:US
Mailing Address - Phone:850-683-0221
Mailing Address - Fax:850-683-0225
Practice Address - Street 1:207 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3543
Practice Address - Country:US
Practice Address - Phone:850-683-0221
Practice Address - Fax:850-683-0225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2947152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620225000Medicaid
FL620225000Medicaid
FL1184830001Medicare NSC
FLU64579Medicare UPIN