Healthcare Provider Details

I. General information

NPI: 1003902479
Provider Name (Legal Business Name): WILSON GYNECOLOGY & FITNESS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SAULSBURY RD
DOVER DE
19904-3444
US

IV. Provider business mailing address

21 SAULSBURY RD
DOVER DE
19904-3444
US

V. Phone/Fax

Practice location:
  • Phone: 302-734-9200
  • Fax: 302-730-8615
Mailing address:
  • Phone: 302-734-9200
  • Fax: 302-730-8615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC10004065
License Number StateDE

VIII. Authorized Official

Name: CALVIN WILSON II
Title or Position: PRESIDENT
Credential: MD
Phone: 302-734-9200