Basic Information
| Provider Information | |||||||||
| NPI: | 1538423769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILKINS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 LYNWOOD FOREST DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630215511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145917887 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5632 TELEGRAPH RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631294243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143347000 | ||||||||
| FaxNumber: | 3143347001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2012 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2012017715 | MO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.