Healthcare Provider Details

I. General information

NPI: 1972598316
Provider Name (Legal Business Name): WILLIAM LE ROY WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date: 03/25/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

5565 GROSSMONT CENTER DR BLDG. 3, SUITE 540
LA MESA CA
91942-3020
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR BLDG. 3, SUITE 540
LA MESA CA
91942-3020
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-2700
  • Fax: 619-460-2702
Mailing address:
  • Phone: 619-460-2700
  • Fax: 619-460-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG44872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: