Provider Demographics
NPI:1689765414
Name:LARRY WILKINSON
Entity type:Organization
Organization Name:LARRY WILKINSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:(NMI)
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:281-342-4664
Mailing Address - Street 1:4000 AVENUE I
Mailing Address - Street 2:P O BOX 607
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-3904
Mailing Address - Country:US
Mailing Address - Phone:281-342-4664
Mailing Address - Fax:281-232-0894
Practice Address - Street 1:4000 AVENUE I
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-3904
Practice Address - Country:US
Practice Address - Phone:281-342-4664
Practice Address - Fax:281-232-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02165T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019274201Medicaid
0235560001Medicare NSC
TX00E24GMedicare PIN
TX80147E3Medicare PIN
614328Medicare PIN