Provider Demographics
NPI:1720465925
Name:WILSON, MARITZA KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:KATHLEEN
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 1:728 E VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3052
Mailing Address - Country:US
Mailing Address - Phone:760-737-6900
Mailing Address - Fax:360-462-2748
Practice Address - Street 1:728 E VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3052
Practice Address - Country:US
Practice Address - Phone:760-737-6900
Practice Address - Fax:360-462-2748
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA146931207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program