Provider Demographics
NPI:1689648966
Name:WILSON, CORY M (MD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:M
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 1:27716 WILDERNESS PL
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-4117
Mailing Address - Country:US
Mailing Address - Phone:661-200-3581
Mailing Address - Fax:
Practice Address - Street 1:27716 WILDERNESS PL
Practice Address - Street 2:
Practice Address - City:CASTAIC
Practice Address - State:CA
Practice Address - Zip Code:91384-4117
Practice Address - Country:US
Practice Address - Phone:661-200-3581
Practice Address - Fax:661-200-3581
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22843207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47042628500Medicaid
NE278843Medicare PIN
NE47042628500Medicaid
G60008Medicare UPIN