Healthcare Provider Details

I. General information

NPI: 1497844559
Provider Name (Legal Business Name): THOMAS IAN WILSON M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 E TUOLUMNE RD
TURLOCK CA
95382-1543
US

IV. Provider business mailing address

911 E TUOLUMNE RD
TURLOCK CA
95382-1543
US

V. Phone/Fax

Practice location:
  • Phone: 209-668-4101
  • Fax: 209-668-3758
Mailing address:
  • Phone: 209-668-4101
  • Fax: 209-668-3758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA33997
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: