Provider Demographics
NPI:1114983467
Name:WILSON, VERNON RAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:RAPHAEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3445 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6658
Mailing Address - Country:US
Mailing Address - Phone:310-937-9200
Mailing Address - Fax:310-937-9522
Practice Address - Street 1:3445 PACIFIC COAST HWY
Practice Address - Street 2:SUITE 220
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6658
Practice Address - Country:US
Practice Address - Phone:310-937-9200
Practice Address - Fax:310-937-9522
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2008-07-01
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Provider Licenses
StateLicense IDTaxonomies
CAG62587207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF16323Medicare UPIN