Healthcare Provider Details

I. General information

NPI: 1184685620
Provider Name (Legal Business Name): ELAINE V. WILSON-COLBERT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 40TH ST SUITE 429
BALTIMORE MD
21211-2120
US

IV. Provider business mailing address

711 W 40TH ST SUITE 429
BALTIMORE MD
21211-2120
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-5437
  • Fax: 410-554-5436
Mailing address:
  • Phone: 410-554-5437
  • Fax: 410-554-5436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0025973
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: