Provider Demographics
NPI:1639140106
Name:WILSON, KATHLEEN GAYLE (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GAYLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 ROBIN HOOD RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-5826
Mailing Address - Country:US
Mailing Address - Phone:904-384-3133
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-270-4220
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H27639Medicare UPIN