Provider Demographics
NPI:1518070119
Name:WILSON, NILOUFAR (MD)
Entity Type:Individual
Prefix:DR
First Name:NILOUFAR
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 1:350 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2733
Mailing Address - Country:US
Mailing Address - Phone:386-238-3289
Mailing Address - Fax:386-238-3296
Practice Address - Street 1:350 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2733
Practice Address - Country:US
Practice Address - Phone:386-238-3289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49062207RC0000X
MN102530207RC0000X
FL143954207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN136617000Medicaid
MNP00413289OtherMEDICARE RAILROAD
MN136617000Medicaid
MN060002302Medicare PIN