Provider Demographics
NPI:1558879296
Name:WILSON, MILLICENT ELAINE (MD)
Entity type:Individual
Prefix:DR
First Name:MILLICENT
Middle Name:ELAINE
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 1:10100 PIONEER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-8299
Mailing Address - Country:US
Mailing Address - Phone:562-347-1648
Mailing Address - Fax:
Practice Address - Street 1:245 S FETTERLY AVE
Practice Address - Street 2:
Practice Address - City:EAST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1605
Practice Address - Country:US
Practice Address - Phone:323-362-1400
Practice Address - Fax:323-362-1373
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG079177207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine