Healthcare Provider Details

I. General information

NPI: 1275513376
Provider Name (Legal Business Name): DONALD R WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 LINDA FALLS TER
ANGWIN CA
94508-9684
US

IV. Provider business mailing address

PO BOX 714
ANGWIN CA
94508-0714
US

V. Phone/Fax

Practice location:
  • Phone: 707-965-2181
  • Fax: 707-965-3576
Mailing address:
  • Phone: 707-965-2181
  • Fax: 707-965-3576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA24934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: