Provider Demographics
NPI:1215933056
Name:WILSON, GARY A (M D)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2781
Mailing Address - Country:US
Mailing Address - Phone:386-947-4650
Mailing Address - Fax:386-947-4690
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2781
Practice Address - Country:US
Practice Address - Phone:386-947-4650
Practice Address - Fax:386-947-4690
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA348582086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0276915Medicaid
IA0276915Medicaid
IAI7627Medicare PIN