Provider Demographics
NPI:1619960457
Name:WILSON, HAROLD T (MD)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:T
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 1:16063 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4810
Mailing Address - Country:US
Mailing Address - Phone:818-785-9989
Mailing Address - Fax:818-785-3330
Practice Address - Street 1:16063 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4810
Practice Address - Country:US
Practice Address - Phone:818-785-9989
Practice Address - Fax:818-785-3330
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 38694208000000X
NC97011992080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619960457OtherTRICARE
NC5910044Medicaid
SC1619960457Medicaid
CAF 51035Medicare UPIN