Provider Demographics
NPI:1407208499
Name:WILSON, TYLER (DO)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BODIN CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-3000
Mailing Address - Fax:
Practice Address - Street 1:UNIT 5024 BOX 35TH
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319-5024
Practice Address - Country:US
Practice Address - Phone:315-226-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2024-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA20A21080207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program