Provider Demographics
NPI:1528149424
Name:RICHARD R WILSON, D.O.
Entity type:Organization
Organization Name:RICHARD R WILSON, D.O.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:REID
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-949-1212
Mailing Address - Street 1:10201 ARCOS AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928
Mailing Address - Country:US
Mailing Address - Phone:239-949-1212
Mailing Address - Fax:239-949-0587
Practice Address - Street 1:10201 ARCOS AVE
Practice Address - Street 2:STE 202
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928
Practice Address - Country:US
Practice Address - Phone:239-949-1212
Practice Address - Fax:239-949-0587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5459Medicare PIN