Healthcare Provider Details

I. General information

NPI: 1275982779
Provider Name (Legal Business Name): DAVID M. WILSON AT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7510 MADISON ST
MERRILLVILLE IN
46410-4609
US

IV. Provider business mailing address

7510 MADISON ST
MERRILLVILLE IN
46410-4609
US

V. Phone/Fax

Practice location:
  • Phone: 219-795-0765
  • Fax:
Mailing address:
  • Phone: 219-781-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000725A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: