Healthcare Provider Details

I. General information

NPI: 1518490754
Provider Name (Legal Business Name): SETH WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 UNIVERSITY PKWY STE 101
SARASOTA FL
34243-5813
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-4675
  • Fax: 941-917-4688
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME143351
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: