Healthcare Provider Details

I. General information

NPI: 1407850365
Provider Name (Legal Business Name): CARLENE A. WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6038 W NORDLING LOOP
CRYSTAL RIVER FL
34429
US

IV. Provider business mailing address

6038 W NORDLING LOOP
CRYSTAL RIVER FL
34429
US

V. Phone/Fax

Practice location:
  • Phone: 352-563-5070
  • Fax: 352-795-4322
Mailing address:
  • Phone: 352-563-5070
  • Fax: 352-795-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME93743
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME93743
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: