Provider Demographics
NPI:1801891130
Name:WILSON, DAVID P (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:FORT JONES
Mailing Address - State:CA
Mailing Address - Zip Code:96032-0458
Mailing Address - Country:US
Mailing Address - Phone:530-468-5766
Mailing Address - Fax:530-842-9054
Practice Address - Street 1:11219 N HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:FORT JONES
Practice Address - State:CA
Practice Address - Zip Code:96032-9731
Practice Address - Country:US
Practice Address - Phone:530-468-5766
Practice Address - Fax:530-842-9054
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2012-01-20
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
CAG37216207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G72161Medicaid
CA00G372162Medicaid
CAG37216OtherMEDICAL LICENSE
CAOOG372162Medicare ID - Type UnspecifiedMEDICARE NUMBER
CA00G72161Medicaid
CAG37216OtherMEDICAL LICENSE