Provider Demographics
NPI:1275513376
Name:WILSON, DONALD R (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 714
Mailing Address - Street 2:
Mailing Address - City:ANGWIN
Mailing Address - State:CA
Mailing Address - Zip Code:94508-0714
Mailing Address - Country:US
Mailing Address - Phone:707-965-2181
Mailing Address - Fax:707-965-3576
Practice Address - Street 1:715 LINDA FALLS TER
Practice Address - Street 2:
Practice Address - City:ANGWIN
Practice Address - State:CA
Practice Address - Zip Code:94508-9684
Practice Address - Country:US
Practice Address - Phone:707-965-2181
Practice Address - Fax:707-965-3576
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24934208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A249340Medicaid
CA00A249340Medicaid
CA00A249340Medicare ID - Type Unspecified