MEDICARE: DR. CARLENE A. WILSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME93743	FL
2	208000000X	Pediatrics Physician	ME93743	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5705127861001	OTHER	SC	BLUE CROSS OF SC
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	30031	OTHER	FL	BLUE CROSS OF FLORIDA

General Provider Information

NPI Number	:	1407850365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLENE A. WILSON M.D.

Provider Business Mailing Address
First Line	:	6038 W NORDLING LOOP
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429
Country	:	US
Telephone Number	:	352-563-5070
Fax Number	:	352-795-4322

Provider Business Practice Location Address
First Line	:	6038 W NORDLING LOOP
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429
Country	:	US
Telephone Number	:	352-563-5070
Fax Number	:	352-795-4322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	06/09/2014

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Directions to “ DR. CARLENE A. WILSON M.D.” Practice Location

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