Healthcare Provider Details

I. General information

NPI: 1679099519
Provider Name (Legal Business Name): WILCO CIVIL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 17TH ST
SAINT CLOUD FL
34769-6006
US

IV. Provider business mailing address

3231 MCMULLEN BOOTH RD FL 1
SAFETY HARBOR FL
34695-6607
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-7856
  • Fax: 321-843-6432
Mailing address:
  • Phone: 727-725-6905
  • Fax: 727-266-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS16855
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS16855
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: