MEDICARE: DWAYNE 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	207P00000X	Emergency Medicine Physician	210137	NY
2	207P00000X	Emergency Medicine Physician	037212	CT
3	207P00000X	Emergency Medicine Physician	11620	RI
4	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	210137	NY
5	2083A0100X	Aerospace Medicine Physician	210137	NY

General Provider Information

NPI Number	:	1578587341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWAYNE WILSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 340773
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-0773
Country	:	US
Telephone Number	:	401-419-6040
Fax Number	:

Provider Business Practice Location Address
First Line	:	2454 CAMP TRAVIS
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7671
Country	:	US
Telephone Number	:	401-419-6040
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	08/07/2010

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