Healthcare Provider Details

I. General information

NPI: 1487613402
Provider Name (Legal Business Name): TIMOTHY R WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 71ST STREET SUITE 620
MIAMI BEACH FL
33141-3089
US

IV. Provider business mailing address

PO BOX 11768
RICHMOND VA
23230-0168
US

V. Phone/Fax

Practice location:
  • Phone: 305-866-9951
  • Fax: 877-284-8933
Mailing address:
  • Phone: 804-353-4000
  • Fax: 804-213-9783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101238898
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: