Basic Information
| Provider Information | |||||||||
| NPI: | 1992722581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 842368 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752842368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669165259 | ||||||||
| FaxNumber: | 2319227403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1635 NORTH LOOP W | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770081532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138672000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L4810 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 154702803 | 05 | TX | MEDICAID | 154702802 | 05 | TX | MEDICAID |