Provider Demographics
NPI:1043235054
Name:WILSON, KENDAL PHILLIP (KENDAL WILSON MD)
Entity Type:Individual
Prefix:DR
First Name:KENDAL
Middle Name:PHILLIP
Last Name:WILSON
Suffix:
Gender:M
Credentials:KENDAL WILSON MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 WATERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4252
Mailing Address - Country:US
Mailing Address - Phone:972-444-0907
Mailing Address - Fax:
Practice Address - Street 1:1600 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6913
Practice Address - Country:US
Practice Address - Phone:817-685-4920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7256208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE14666Medicare UPIN