Healthcare Provider Details

I. General information

NPI: 1619960457
Provider Name (Legal Business Name): HAROLD T WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16063 VANOWEN ST
VAN NUYS CA
91406-4810
US

IV. Provider business mailing address

16063 VANOWEN ST
VAN NUYS CA
91406-4810
US

V. Phone/Fax

Practice location:
  • Phone: 818-785-9989
  • Fax: 818-785-3330
Mailing address:
  • Phone: 818-785-9989
  • Fax: 818-785-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA 38694
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number9701199
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: