Provider Demographics
NPI:1326468901
Name:WILSON, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:1050 E. HWY. 114
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-4917
Mailing Address - Country:US
Mailing Address - Phone:817-329-8364
Mailing Address - Fax:817-329-1285
Practice Address - Street 1:1050 E. HWY. 114
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4917
Practice Address - Country:US
Practice Address - Phone:817-329-8364
Practice Address - Fax:817-329-1285
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine