Provider Demographics
NPI:1528778156
Name:WILSON, ERIC L
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94603-2558
Mailing Address - Country:US
Mailing Address - Phone:510-777-1177
Mailing Address - Fax:
Practice Address - Street 1:1919 MARKET ST UNIT 313
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2762
Practice Address - Country:US
Practice Address - Phone:510-993-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center