Provider Demographics
NPI:1497844559
Name:WILSON, THOMAS IAN (MD,)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:IAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 E TUOLUMNE RD
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-1543
Mailing Address - Country:US
Mailing Address - Phone:209-668-4101
Mailing Address - Fax:209-668-3758
Practice Address - Street 1:911 E TUOLUMNE RD
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1543
Practice Address - Country:US
Practice Address - Phone:209-668-4101
Practice Address - Fax:209-668-3758
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0003770Medicaid
CAGR0003770Medicaid
CAZZZ86221ZMedicare ID - Type Unspecified