Provider Demographics
NPI:1417190869
Name:WILSON, THADDEUS DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 GARDENDALE ST
Mailing Address - Street 2:SUITE 312
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3132
Mailing Address - Country:US
Mailing Address - Phone:210-293-6003
Mailing Address - Fax:
Practice Address - Street 1:4204 GARDENDALE ST
Practice Address - Street 2:SUITE 312
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3132
Practice Address - Country:US
Practice Address - Phone:210-293-6003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4343207PP0204X
TN58235207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine