Provider Demographics
NPI:1043522618
Name:WILSON, DWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6100 BLUE LAGOON DR STE 365
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-7010
Mailing Address - Country:US
Mailing Address - Phone:786-322-7333
Mailing Address - Fax:786-322-7329
Practice Address - Street 1:3978 W HILLSBOROUGH AVE UNIT 21B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5628
Practice Address - Country:US
Practice Address - Phone:813-906-1412
Practice Address - Fax:813-413-1971
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121189207R00000X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine