Healthcare Provider Details

I. General information

NPI: 1801848312
Provider Name (Legal Business Name): DAN E WILSON JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HOLDERRIETH BLVD SUITE206
TOMBALL TX
77375-4543
US

IV. Provider business mailing address

425 HOLDERRIETH BLVD SUITE206
TOMBALL TX
77375-4543
US

V. Phone/Fax

Practice location:
  • Phone: 281-357-5454
  • Fax: 281-357-5499
Mailing address:
  • Phone: 281-357-5454
  • Fax: 281-357-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberK-6414
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: