Provider Demographics
NPI:1740675834
Name:WILSON, LINDA HIMOT (MD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:HIMOT
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:J
Other - Last Name:HIMOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,
Mailing Address - Street 1:P.O.B 125
Mailing Address - Street 2:
Mailing Address - City:BLUE GRASS
Mailing Address - State:VA
Mailing Address - Zip Code:24413
Mailing Address - Country:US
Mailing Address - Phone:434-249-6196
Mailing Address - Fax:
Practice Address - Street 1:1161 LONG VIEW LANE
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:VA
Practice Address - Zip Code:24465
Practice Address - Country:US
Practice Address - Phone:434-249-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009681E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry