Healthcare Provider Details

I. General information

NPI: 1184051906
Provider Name (Legal Business Name): DAVID GEORGE WILSON MPO, CP, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2013
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 HARRY HINES BLVD SUITE V2.302
DALLAS TX
75390-9091
US

IV. Provider business mailing address

6011 HARRY HINES BLVD SUITE V5.400
DALLAS TX
75390-9091
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-8254
  • Fax: 214-645-8258
Mailing address:
  • Phone: 214-645-8254
  • Fax: 214-645-8258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1625
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: