Healthcare Provider Details

I. General information

NPI: 1790033959
Provider Name (Legal Business Name): DONALD R. WILSON, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2012
Last Update Date: 08/20/2012
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: DR. DONALD RICHARD WILSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 707-965-2181