Provider Demographics
NPI:1275982779
Name:WILSON, DAVID M (AT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-4609
Mailing Address - Country:US
Mailing Address - Phone:219-781-0765
Mailing Address - Fax:
Practice Address - Street 1:7510 MADISON ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-4609
Practice Address - Country:US
Practice Address - Phone:219-795-0765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000725A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer