Provider Demographics
NPI:1124194006
Name:WILSON, KIM A (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 CLAYPIT HILL RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-2004
Mailing Address - Country:US
Mailing Address - Phone:508-358-7841
Mailing Address - Fax:
Practice Address - Street 1:75 BICKFORD ST
Practice Address - Street 2:MARTHA ELIOT HEALTH CENTER
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1401
Practice Address - Country:US
Practice Address - Phone:617-971-2312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76388208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3150620Medicaid
J12762Medicare ID - Type Unspecified
F33685Medicare UPIN