Provider Demographics
NPI:1063559631
Name:WISON, DERWIN LEWIS
Entity type:Individual
Prefix:MR
First Name:DERWIN
Middle Name:LEWIS
Last Name:WISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 OLD DENTON RD APT 1803
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007
Mailing Address - Country:US
Mailing Address - Phone:817-996-7456
Mailing Address - Fax:
Practice Address - Street 1:3640 OLD DENTON RD APT 1803
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-7944
Practice Address - Country:US
Practice Address - Phone:817-996-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies