Healthcare Provider Details

I. General information

NPI: 1265455935
Provider Name (Legal Business Name): JOHN WILSON SAMPLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72780 COUNTRY CLUB DR BLDG B 205-B
RANCHO MIRAGE CA
92270-4126
US

IV. Provider business mailing address

72780 COUNTRY CLUB DR BLDG B 205-B
RANCHO MIRAGE CA
92270-4126
US

V. Phone/Fax

Practice location:
  • Phone: 760-834-7900
  • Fax: 760-834-7901
Mailing address:
  • Phone: 760-834-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA66241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: