Provider Demographics
NPI:1164553236
Name:WILSON, RONALD DEAN
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:DEAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93156
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-3156
Mailing Address - Country:US
Mailing Address - Phone:606-826-1367
Mailing Address - Fax:
Practice Address - Street 1:14550 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2210
Practice Address - Country:US
Practice Address - Phone:818-908-4990
Practice Address - Fax:818-997-3138
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner