Healthcare Provider Details

I. General information

NPI: 1023034725
Provider Name (Legal Business Name): DOUGLAS LEE WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5383 HOLLISTER AVE STE 160
GOLETA CA
93111-2357
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 805-565-0020
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA81870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: