Healthcare Provider Details

I. General information

NPI: 1184735730
Provider Name (Legal Business Name): KATHRYN A. S. WILSON DO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 S RICHARDS RUN
SPRINGBORO OH
45066-8003
US

IV. Provider business mailing address

70 SOUTHFIELD CT
SPRINGBORO OH
45066-9268
US

V. Phone/Fax

Practice location:
  • Phone: 937-748-9051
  • Fax: 937-748-9054
Mailing address:
  • Phone: 800-357-5728
  • Fax: 937-291-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN A. WILSON
Title or Position: OWNER
Credential: DO
Phone: 937-748-9051