Provider Demographics
NPI:1720159692
Name:WILSON, DIANA LORRAINE (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LORRAINE
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 1:1209 E CUMBERLAND AVE
Mailing Address - Street 2:UNIT 2505
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4256
Mailing Address - Country:US
Mailing Address - Phone:704-575-8825
Mailing Address - Fax:
Practice Address - Street 1:1209 E CUMBERLAND AVE
Practice Address - Street 2:UNIT 2505
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4256
Practice Address - Country:US
Practice Address - Phone:704-575-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA077328207V00000X
FLME107646207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA239379OtherANTHEM HEALTHKEEPERS
VA239379OtherANTHEM HEALTHKEEPERS