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General NPI Number Information
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NPI Number | 1952694549
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Entity Type | Individual
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Provider Name | BENJAMIN J WILSON MD
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Gender | Male
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Dates
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Enumeration Date | 05/16/2011
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Last Update Date | 05/23/2023
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Provider Practice Location Address
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Address Line | 1908 BOOTHE CIR
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City | LONGWOOD
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State | FL
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Zip | 32750-6774
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Country | US
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Telephone | 844-665-4827
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Fax | 855-437-3395
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Provider Business Mailing Address
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Address Line | 1932 E STAR LN
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City | MERIDIAN
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State | ID
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Zip | 83646-5559
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Country | US
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Telephone | 208-547-5697
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Fax | 208-649-2658
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 8438943-1205
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD60771670
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License Number State | WA
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