Provider Demographics
NPI:1912943168
Name:WILSON, JAMES M (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PLZ
Mailing Address - Street 2:365 A& B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:310-206-7662
Mailing Address - Fax:310-794-6553
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:STE.# 365
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045
Practice Address - Country:US
Practice Address - Phone:310-206-7662
Practice Address - Fax:310-794-6553
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA75466207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912943168Medicaid
CAWA75466EMedicare PIN
CA1912943168Medicaid
CABU408XMedicare PIN
CAWA75466BMedicare PIN
CAWA75466DMedicare PIN