Provider Demographics
NPI:1003902479
Name:WILSON GYNECOLOGY & FITNESS PA
Entity Type:Organization
Organization Name:WILSON GYNECOLOGY & FITNESS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON II
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-734-9200
Mailing Address - Street 1:21 SAULSBURY RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3444
Mailing Address - Country:US
Mailing Address - Phone:302-734-9200
Mailing Address - Fax:302-730-8615
Practice Address - Street 1:21 SAULSBURY RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3444
Practice Address - Country:US
Practice Address - Phone:302-734-9200
Practice Address - Fax:302-730-8615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10004065174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE731682Medicare ID - Type Unspecified