Provider Demographics
NPI:1225246978
Name:WILSON, PANDORA KIM (DO)
Entity type:Individual
Prefix:DR
First Name:PANDORA
Middle Name:KIM
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 BLOOMFIELD PLACE DR
Mailing Address - Street 2:APT 530B
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0887
Mailing Address - Country:US
Mailing Address - Phone:562-233-4315
Mailing Address - Fax:
Practice Address - Street 1:7007 POWERS BLVD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5437
Practice Address - Country:US
Practice Address - Phone:440-743-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.005822207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine