MEDICARE: DR. DIANA ELIZABETH 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	207T00000X	Neurological Surgery Physician	J0729	TX

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

General Provider Information

NPI Number	:	1538152400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANA ELIZABETH WILSON M.D.

Provider Business Mailing Address
First Line	:	1001 12TH AVE STE 171
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3926
Country	:	US
Telephone Number	:	817-576-6500
Fax Number	:	682-703-2064

Provider Business Practice Location Address
First Line	:	1001 12TH AVE STE 171
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3926
Country	:	US
Telephone Number	:	817-576-6500
Fax Number	:	682-703-2064

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

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	05/21/2025

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