Provider Demographics
NPI:1447314000
Name:WILSON, QUANG VAN (OD)
Entity type:Individual
Prefix:DR
First Name:QUANG
Middle Name:VAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:800 BAYSHORE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-3404
Mailing Address - Country:US
Mailing Address - Phone:850-791-9659
Mailing Address - Fax:850-458-4946
Practice Address - Street 1:2951 S BLUE ANGEL PKWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-6906
Practice Address - Country:US
Practice Address - Phone:850-455-8155
Practice Address - Fax:850-458-4946
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP3066152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist