Provider Demographics
NPI:1568525681
Name:WILSON, DONALD KERRY (DC)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:KERRY
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3626
Mailing Address - Country:US
Mailing Address - Phone:530-753-2182
Mailing Address - Fax:530-753-0346
Practice Address - Street 1:639 OAK AVENUE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:530-753-2182
Practice Address - Fax:530-753-0346
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
T04368Medicare UPIN
DC0115350Medicare ID - Type Unspecified