Provider Demographics
NPI:1093757569
Name:LINDA O. WILSON M.D. P.A.
Entity Type:Organization
Organization Name:LINDA O. WILSON M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:ORNELAS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-575-0500
Mailing Address - Street 1:2806 N NAVARRO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-3905
Mailing Address - Country:US
Mailing Address - Phone:361-575-0500
Mailing Address - Fax:361-574-9057
Practice Address - Street 1:2806 N NAVARRO ST
Practice Address - Street 2:SUITE C
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-3905
Practice Address - Country:US
Practice Address - Phone:361-575-0500
Practice Address - Fax:361-574-9057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1253174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00197WMedicare ID - Type Unspecified
TX97832Medicare UPIN