Provider Demographics
NPI:1942396304
Name:WILSON, CALVIN THOMAS II (MD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:THOMAS
Last Name:WILSON
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SAULSBURY RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3444
Mailing Address - Country:US
Mailing Address - Phone:302-734-9200
Mailing Address - Fax:302-730-8615
Practice Address - Street 1:21 SAULSBURY RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3444
Practice Address - Country:US
Practice Address - Phone:302-734-9200
Practice Address - Fax:302-730-8615
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10004065174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEF50969Medicare UPIN