Healthcare Provider Details

I. General information

NPI: 1326084641
Provider Name (Legal Business Name): ODELL WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE PEDIATRIX MEDICAL GROUP
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

7348 OLD PECOS TRL NE
ALBUQUERQUE NM
87113-1322
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-6392
  • Fax: 505-563-6390
Mailing address:
  • Phone: 505-563-6392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD2004-0224
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: