=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528021417
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD REID WILSON D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2006
-----------------------------------------------------
Last Update Date | 07/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9250 CORKSCREW RD STE 5
-----------------------------------------------------
City | ESTERO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-949-1212
-----------------------------------------------------
Fax | 239-791-1228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9250 CORKSCREW RD STE 5
-----------------------------------------------------
City | ESTERO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33928-3216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-949-1212
-----------------------------------------------------
Fax | 392-791-1228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS9100
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------