Provider Demographics
NPI:1831274976
Name:FREDERICK S WILSON DPM INC
Entity type:Organization
Organization Name:FREDERICK S WILSON DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:SAUL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:510-796-2191
Mailing Address - Street 1:1895 MOWRY AVE
Mailing Address - Street 2:STE. 103
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1737
Mailing Address - Country:US
Mailing Address - Phone:510-796-2191
Mailing Address - Fax:510-796-2250
Practice Address - Street 1:1895 MOWRY AVE
Practice Address - Street 2:STE. 103
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1737
Practice Address - Country:US
Practice Address - Phone:510-796-2191
Practice Address - Fax:510-796-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2105213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty