Provider Demographics
NPI:1316993272
Name:WILSON, KATHLEEN WOODHOUSE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:WOODHOUSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24600 S TAMIAMI TRL
Mailing Address - Street 2:STE 212 BOX 308
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7022
Mailing Address - Country:US
Mailing Address - Phone:239-390-1562
Mailing Address - Fax:239-948-9042
Practice Address - Street 1:24810 BURNT PINE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-1973
Practice Address - Country:US
Practice Address - Phone:239-495-0439
Practice Address - Fax:239-495-2688
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94454207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00668209OtherRAIL ROAD MEDICARE
31155WMedicare PIN
FLP00668209OtherRAIL ROAD MEDICARE
FLA01773Medicare UPIN
31155WMedicare PIN