Basic Information
| Provider Information | |||||||||
| NPI: | 1053648626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DEISHA | ||||||||
| MiddleName: | MALONES | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499233277 | ||||||||
| FaxNumber: | 8558125865 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 THUNDER DR | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920836010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609419002 | ||||||||
| FaxNumber: | 7606302515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2009 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A11676 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.