Provider Demographics
NPI:1366645350
Name:WILSON, MELISSA (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:110 MEDICAL DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-3127
Mailing Address - Country:US
Mailing Address - Phone:361-578-5233
Mailing Address - Fax:
Practice Address - Street 1:110 MEDICAL DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-3127
Practice Address - Country:US
Practice Address - Phone:361-578-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXM6957207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology