Basic Information
| Provider Information | |||||||||
| NPI: | 1720123391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7520 TRANSOM CT | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336075863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275351437 | ||||||||
| FaxNumber: | 7275354190 | ||||||||
| Practice Location | |||||||||
| Address1: | 7520 TRANSOM CT | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336075863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275351437 | ||||||||
| FaxNumber: | 7275354190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1002X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Corpsman |
No ID Information.