Provider Demographics
NPI:1790059970
Name:WILSON, DIANA L (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
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 1:7918 VERSILIA DR.
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836
Mailing Address - Country:US
Mailing Address - Phone:407-354-3765
Mailing Address - Fax:
Practice Address - Street 1:9582 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-6992
Practice Address - Country:US
Practice Address - Phone:407-363-6700
Practice Address - Fax:407-865-6012
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME785062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology