Healthcare Provider Details

I. General information

NPI: 1508864653
Provider Name (Legal Business Name): PETER J WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 N COVE BLVD
TOLEDO OH
43606-3895
US

IV. Provider business mailing address

2914 S REPUBLIC BLVD
TOLEDO OH
43615-1912
US

V. Phone/Fax

Practice location:
  • Phone: 419-471-4491
  • Fax: 419-479-6905
Mailing address:
  • Phone: 419-531-8808
  • Fax: 419-531-9342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35049169
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number350149169
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: