Provider Demographics
NPI:1578623559
Name:VANESSA V. WILSON, M.D.
Entity Type:Organization
Organization Name:VANESSA V. WILSON, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:MATILDE
Authorized Official - Middle Name:DALIT
Authorized Official - Last Name:ABDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-792-2058
Mailing Address - Street 1:680 MOWRY AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4113
Mailing Address - Country:US
Mailing Address - Phone:510-792-1977
Mailing Address - Fax:510-792-2499
Practice Address - Street 1:680 MOWRY AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4113
Practice Address - Country:US
Practice Address - Phone:510-792-1977
Practice Address - Fax:510-792-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A492610Medicare ID - Type Unspecified