Provider Demographics
NPI:1942721873
Name:WILSON, ZACHARY DEWITT (IDC)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:DEWITT
Last Name:WILSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5552 GENESEE CT E APT 136
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3035
Mailing Address - Country:US
Mailing Address - Phone:423-361-6112
Mailing Address - Fax:
Practice Address - Street 1:22 AREA REGIMENTAL AID STATION
Practice Address - Street 2:1ST MEDICAL BATTALION
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5657
Practice Address - Country:US
Practice Address - Phone:760-725-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman