Healthcare Provider Details

I. General information

NPI: 1124093661
Provider Name (Legal Business Name): PETER B WILTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 BEAM AVE STE 302
MAPLEWOOD MN
55109
US

IV. Provider business mailing address

310 SMITH AVE N
SAINT PAUL MN
55102-2383
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-6351
  • Fax:
Mailing address:
  • Phone: 952-843-4333
  • Fax: 952-843-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number29713
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: