Provider Demographics
NPI:1891890885
Name:WILSON, DIANA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
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 1:76 HIGH ST
Mailing Address - Street 2:STE 300
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7649
Mailing Address - Country:US
Mailing Address - Phone:207-795-5544
Mailing Address - Fax:207-795-5645
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-5338
Practice Address - Fax:207-795-5645
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016172207RP1001X
VT042.0014136207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEH85089Medicare UPIN
MEMM996503Medicare PIN
MERX4165Medicare PIN
MEMM996501Medicare PIN
MEMM996502Medicare PIN