Basic Information
| Provider Information | |||||||||
| NPI: | 1366050361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | IRIS | ||||||||
| MiddleName: | MIGDALIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 TAVISTOCK LAKES BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328277592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213326947 | ||||||||
| FaxNumber: | 4072864515 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 VILLAGE OAK LN | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347466558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075203588 | ||||||||
| FaxNumber: | 4079786757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2020 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 15150 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 21972 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN1344 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.