Healthcare Provider Details

I. General information

NPI: 1043522618
Provider Name (Legal Business Name): DWAYNE WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3978 W HILLSBOROUGH AVE UNIT 21B
TAMPA FL
33614-5628
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 365
MIAMI FL
33126-7010
US

V. Phone/Fax

Practice location:
  • Phone: 813-906-1412
  • Fax: 813-413-1971
Mailing address:
  • Phone: 786-322-7333
  • Fax: 786-322-7329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME121189
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberME121189
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: