Provider Demographics
NPI:1194772525
Name:WILSON, SONE-SEERE A (MD)
Entity type:Individual
Prefix:
First Name:SONE-SEERE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 RAVENNA DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-3613
Mailing Address - Country:US
Mailing Address - Phone:562-754-0703
Mailing Address - Fax:
Practice Address - Street 1:1115 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3940
Practice Address - Country:US
Practice Address - Phone:626-814-2434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59162207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G519620Medicaid
CAWG59162IMedicare PIN
F12103Medicare UPIN
CAAR596ZMedicare PIN