Provider Demographics
NPI:1861463861
Name:WILSON, LINDA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:CASSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:116 PARSONS PARK DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6066
Practice Address - Country:US
Practice Address - Phone:813-681-6625
Practice Address - Fax:813-684-6043
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118638207V00000X
PAMD026147E207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012103000Medicaid
PA000866973Medicaid
PA232359401OtherMAIN LINE HEALTHCARE
PA232359401OtherMAIN LINE HEALTHCARE
FL012103000Medicaid
PA046088HK1Medicare PIN