Healthcare Provider Details

I. General information

NPI: 1518065861
Provider Name (Legal Business Name): SAMUEL ERIC WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S SUITE 810 CITY TOWER
ORANGE CA
92868-3201
US

IV. Provider business mailing address

1436 VIA CASTILLA
PALOS VERDES ESTATES CA
90274-2800
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7246
  • Fax: 714-456-8205
Mailing address:
  • Phone: 714-456-7246
  • Fax: 714-456-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberC28352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: