Provider Demographics
NPI:1346297694
Name:WILSON, SELMA P (MD)
Entity Type:Individual
Prefix:
First Name:SELMA
Middle Name:P
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 93117
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79493
Mailing Address - Country:US
Mailing Address - Phone:806-796-7246
Mailing Address - Fax:806-791-1462
Practice Address - Street 1:4102 24TH ST
Practice Address - Street 2:SUITE 409
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1806
Practice Address - Country:US
Practice Address - Phone:806-796-7246
Practice Address - Fax:806-791-1462
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7850207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88J768Medicare PIN