Provider Demographics
NPI:1235353038
Name:WILSON, DAVID TIMOTHY (DPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:TIMOTHY
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10219 PINEWOOD AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-2495
Mailing Address - Country:US
Mailing Address - Phone:626-449-9909
Mailing Address - Fax:
Practice Address - Street 1:150 N HILL AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1907
Practice Address - Country:US
Practice Address - Phone:626-449-9909
Practice Address - Fax:626-449-9921
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT24579Medicare ID - Type UnspecifiedMED INDIVIDUAL PROV#
CAW18032AMedicare ID - Type UnspecifiedGLENDALE MED PROV #
CAW18032BMedicare ID - Type UnspecifiedCULVER MED PROV #
CAW18032Medicare ID - Type UnspecifiedPASADENA MEDICARE PROV #