Healthcare Provider Details

I. General information

NPI: 1386271161
Provider Name (Legal Business Name): ERIC CHRISTOPHER WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W OAK ST STE 201
KISSIMMEE FL
34741-4998
US

IV. Provider business mailing address

7574 FORREST SHADOW LN
BARTLETT TN
38002-7502
US

V. Phone/Fax

Practice location:
  • Phone: 407-518-3347
  • Fax:
Mailing address:
  • Phone: 407-774-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number33286
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number71067
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: