Provider Demographics
NPI:1386604072
Name:WILSON, DAVID B (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:640 KOLTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3570
Mailing Address - Country:US
Mailing Address - Phone:724-357-7333
Mailing Address - Fax:724-465-0193
Practice Address - Street 1:120 IRMC DR
Practice Address - Street 2:SUITE 160
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3674
Practice Address - Country:US
Practice Address - Phone:724-465-2676
Practice Address - Fax:724-349-1830
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065847L207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017454620003Medicaid
PACI1160OtherRAILROAD MEDICARE
PA0017454620003Medicaid
PAG70825Medicare UPIN