Provider Demographics
NPI:1679569495
Name:WILSON, WENDIANNE M (OD)
Entity type:Individual
Prefix:DR
First Name:WENDIANNE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 86TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-1026
Mailing Address - Country:US
Mailing Address - Phone:515-727-6340
Mailing Address - Fax:515-727-5109
Practice Address - Street 1:4660 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-1026
Practice Address - Country:US
Practice Address - Phone:515-727-6340
Practice Address - Fax:515-727-5109
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2001152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3086538Medicaid
IAI6355Medicare ID - Type UnspecifiedGROUP NUMBER
IAI6358Medicare ID - Type Unspecified
IA3086538Medicaid