Provider Demographics
NPI:1467638924
Name:VINCENT PAUL WILSON MD,PA
Entity Type:Organization
Organization Name:VINCENT PAUL WILSON MD,PA
Other - Org Name:MAITLAND PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-678-3255
Mailing Address - Street 1:301 S MAITLAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5631
Mailing Address - Country:US
Mailing Address - Phone:407-678-3255
Mailing Address - Fax:
Practice Address - Street 1:301 S MAITLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5631
Practice Address - Country:US
Practice Address - Phone:407-678-3255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG81425Medicare UPIN