Healthcare Provider Details

I. General information

NPI: 1770014755
Provider Name (Legal Business Name): AUGUSTINE REID WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
OCEANSIDE CA
92055
US

IV. Provider business mailing address

1740 EAGLES NEST WAY APT 319
OCEANSIDE CA
92058-7181
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1288
  • Fax:
Mailing address:
  • Phone: 312-358-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA183527
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125070644
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: