Provider Demographics
NPI:1528021417
Name:WILSON, RICHARD REID (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:REID
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 CORKSCREW RD STE 5
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-3216
Mailing Address - Country:US
Mailing Address - Phone:239-949-1212
Mailing Address - Fax:392-791-1228
Practice Address - Street 1:9250 CORKSCREW RD STE 5
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928
Practice Address - Country:US
Practice Address - Phone:239-949-1212
Practice Address - Fax:239-791-1228
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37396ZMedicare PIN