Provider Demographics
NPI:1457468928
Name:WILSON, KIM (MD)
Entity Type:Individual
Prefix:
First Name:KIM
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:PO BOX 198441
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8441
Mailing Address - Country:US
Mailing Address - Phone:813-745-7365
Mailing Address - Fax:813-449-8618
Practice Address - Street 1:1905 N PLACITA CARTAMO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85749-9203
Practice Address - Country:US
Practice Address - Phone:813-745-7365
Practice Address - Fax:813-449-8618
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ274382085B0100X
FLME737182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging