Provider Demographics
NPI:1467701789
Name:WILSON, KERWIN WAYNE (ORTHOTIC FITTER)
Entity Type:Individual
Prefix:MR
First Name:KERWIN
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:ORTHOTIC FITTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7474 SKILLMAN ST. # 501
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231
Mailing Address - Country:US
Mailing Address - Phone:214-966-3342
Mailing Address - Fax:214-221-1593
Practice Address - Street 1:7474 SKILLMAN ST. # 501
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231
Practice Address - Country:US
Practice Address - Phone:214-966-3342
Practice Address - Fax:214-221-1593
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies