Provider Demographics
NPI:1750946117
Name:WILSON, DANIELLE D (DO)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7031 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4701
Mailing Address - Country:US
Mailing Address - Phone:305-284-7761
Mailing Address - Fax:
Practice Address - Street 1:245 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4852
Practice Address - Country:US
Practice Address - Phone:909-793-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A21636207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine