Provider Demographics
NPI:1184839896
Name:WILSON, THADDEUS EARL (MD)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:EARL
Last Name:WILSON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:11406 LOMA LINDA DRIVE
Mailing Address - Street 2:PHYSICAL MEDICINE AND REHABILITATION
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-6275
Mailing Address - Fax:909-558-6212
Practice Address - Street 1:11406 LOMA LINDA DR
Practice Address - Street 2:PHYSICAL MEDICINE AND REHABILITATION
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3711
Practice Address - Country:US
Practice Address - Phone:909-558-6275
Practice Address - Fax:909-558-6212
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2014-08-15
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Provider Licenses
StateLicense IDTaxonomies
CAA1022612081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine