Healthcare Provider Details

I. General information

NPI: 1669009775
Provider Name (Legal Business Name): CAMILLE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

7432 SAINTSBURY PL
RANCHO CUCAMONGA CA
91739-8563
US

V. Phone/Fax

Practice location:
  • Phone: 909-922-4889
  • Fax:
Mailing address:
  • Phone: 909-922-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA188246
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: