Individual
DR. DIANE G WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.D.
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
T02765
MO
152WP0200X
Pediatric Optometrist
T02765
MO
152WV0400X
Vision Therapy Optometrist
T02765
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
108374
BLUE CROSS/BLUE SHIELD
MO
01
—
20717
BLUE CHOICE
MO
01
—
22-02076
UNITED HEALTHCARE
MO
01
—
401231
GROUP HEALTH PLAN
MO
Enumeration date
06/21/2006
Last updated
12/22/2008
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