Provider Demographics
NPI:1437157526
Name:WILSON, LYMAN HAROLD (DPM)
Entity Type:Individual
Prefix:
First Name:LYMAN
Middle Name:HAROLD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1038 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2111
Mailing Address - Country:US
Mailing Address - Phone:714-771-4191
Mailing Address - Fax:714-771-2731
Practice Address - Street 1:1038 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2111
Practice Address - Country:US
Practice Address - Phone:714-771-4191
Practice Address - Fax:714-771-2731
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1288213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E12880Medicaid
CA0690220001OtherDMERC SUPPLIER NUMBER
CA8961126Medicare ID - Type Unspecified
CA000E12880Medicaid