Healthcare Provider Details

I. General information

NPI: 1992988612
Provider Name (Legal Business Name): MITCHELL DAVID WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 PIEDMONT AVE
BERKELEY CA
94705-2344
US

IV. Provider business mailing address

2960 PIEDMONT AVE
BERKELEY CA
94705-2344
US

V. Phone/Fax

Practice location:
  • Phone: 510-843-4660
  • Fax: 510-843-4675
Mailing address:
  • Phone: 510-843-4660
  • Fax: 510-843-4675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG56456
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: