Provider Demographics
NPI:1275976425
Name:WILSON, SARAH ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ELIZABETH
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:PO BOX 60465
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0465
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-884-1912
Practice Address - Street 1:3315 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1820
Practice Address - Country:US
Practice Address - Phone:361-761-1400
Practice Address - Fax:361-884-1912
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ2221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345626101Medicaid