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General NPI Number Information
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NPI Number | 1932510963
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Entity Type | Individual
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Provider Name | ILAVENIL WILSON M.D.,
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Gender | Female
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 12/06/2021
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Provider Practice Location Address
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Address Line | 25805 BARTON RD STE 107
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City | LOMA LINDA
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State | CA
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Zip | 92354-3890
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Country | US
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Telephone | 909-709-1975
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Fax |
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Provider Business Mailing Address
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Address Line | 193 N PLYMOUTH WAY
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-4122
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Country | US
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Telephone | 909-709-1975
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | A143922
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | A143922
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | A143922
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License Number State | CA
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