Provider Demographics
NPI:1255323325
Name:CARL WILSON MD INC & JILL EDISON MD
Entity type:Organization
Organization Name:CARL WILSON MD INC & JILL EDISON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-527-9510
Mailing Address - Street 1:435 DOYLE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4515
Mailing Address - Country:US
Mailing Address - Phone:707-527-9510
Mailing Address - Fax:707-527-1306
Practice Address - Street 1:435 DOYLE PARK DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4515
Practice Address - Country:US
Practice Address - Phone:707-527-9510
Practice Address - Fax:707-527-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44318207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty