Provider Demographics
NPI:1679738132
Name:WILSON, ELIZABETH S (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 YALE PL
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4611
Mailing Address - Country:US
Mailing Address - Phone:719-285-2700
Mailing Address - Fax:719-285-2975
Practice Address - Street 1:614 YALE PL
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4611
Practice Address - Country:US
Practice Address - Phone:719-285-2700
Practice Address - Fax:719-285-2975
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50901208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics