Provider Demographics
NPI:1720053572
Name:WILSON, NATHAN JEROME (DO)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:JEROME
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 1:4221 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-1903
Mailing Address - Country:US
Mailing Address - Phone:310-720-0758
Mailing Address - Fax:
Practice Address - Street 1:4221 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-1903
Practice Address - Country:US
Practice Address - Phone:310-720-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine