Provider Demographics
NPI:1659647550
Name:WILSON, THOMAS COOPER (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:COOPER
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 1:625 6TH AVE S STE 450
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4629
Mailing Address - Country:US
Mailing Address - Phone:727-898-2663
Mailing Address - Fax:727-568-6836
Practice Address - Street 1:625 6TH AVE S STE 450
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:251-533-3852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10332056-1205207XP3100X
FLME137286207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery