Provider Demographics
NPI:1407850365
Name:WILSON, CARLENE A (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLENE
Middle Name:A
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 1:6038 W NORDLING LOOP
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429
Mailing Address - Country:US
Mailing Address - Phone:352-563-5070
Mailing Address - Fax:352-795-4322
Practice Address - Street 1:6038 W NORDLING LOOP
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429
Practice Address - Country:US
Practice Address - Phone:352-563-5070
Practice Address - Fax:352-795-4322
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93743207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC271841Medicaid
FL273971200Medicaid
SC5705127861001OtherBLUE CROSS OF SC
SCGP0237Medicaid
GA428955383AMedicaid
FL30031OtherBLUE CROSS OF FLORIDA
SC5705127861001OtherBLUE CROSS OF SC
FLI17924Medicare UPIN
FLK9178Medicare ID - Type Unspecified