Healthcare Provider Details

I. General information

NPI: 1871593764
Provider Name (Legal Business Name): CARMEN JOSEFA WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W SUGARLAND HWY
CLEWISTON FL
33440
US

IV. Provider business mailing address

PO BOX 162264
ALTAMONTE SPRINGS FL
32716-2264
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-2020
  • Fax:
Mailing address:
  • Phone: 941-792-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number044609
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME140321
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: