Provider Demographics
NPI:1790033959
Name:DONALD R. WILSON, M.D., INC.
Entity Type:Organization
Organization Name:DONALD R. WILSON, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-965-2181
Mailing Address - Street 1:PO BOX 714
Mailing Address - Street 2:
Mailing Address - City:ANGWIN
Mailing Address - State:CA
Mailing Address - Zip Code:94508-0714
Mailing Address - Country:US
Mailing Address - Phone:707-965-2181
Mailing Address - Fax:707-965-3576
Practice Address - Street 1:715 LINDA FALLS TER
Practice Address - Street 2:
Practice Address - City:ANGWIN
Practice Address - State:CA
Practice Address - Zip Code:94508-9684
Practice Address - Country:US
Practice Address - Phone:707-965-2181
Practice Address - Fax:707-965-3576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24934208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA249340Medicaid
127551376OtherNPI(INDIVIDUAL)
127551376OtherNPI(INDIVIDUAL)