MEDICARE: KEITH WILSON

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	207V00000X	Obstetrics & Gynecology Physician	G49347	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G493470	OTHER	CA	MEDI CAL #

General Provider Information

NPI Number	:	1730183344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH WILSON

Provider Business Mailing Address
First Line	:	1401 N MONTEBELLO BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640-2584
Country	:	US
Telephone Number	:	714-478-2253
Fax Number	:	323-889-7819

Provider Business Practice Location Address
First Line	:	1401 N MONTEBELLO BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640-2584
Country	:	US
Telephone Number	:	714-478-2253
Fax Number	:	323-889-7819

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	03/10/2021

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Directions to “ KEITH WILSON ” Practice Location

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