Provider Demographics
NPI:1821595877
Name:WILSON, DIVA VITEARE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIVA
Middle Name:VITEARE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIVA
Other - Middle Name:VITEARE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1288 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5245
Mailing Address - Country:US
Mailing Address - Phone:712-328-8800
Mailing Address - Fax:712-328-8461
Practice Address - Street 1:1288 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5245
Practice Address - Country:US
Practice Address - Phone:712-328-8800
Practice Address - Fax:712-328-8461
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-48710207Q00000X
NE33607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine