Provider Demographics
NPI:1912005422
Name:WILSON, TIMOTHY (MD)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
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 1:1333 S MAYFLOWER AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4066
Mailing Address - Country:US
Mailing Address - Phone:626-775-3514
Mailing Address - Fax:626-408-3911
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-582-7137
Practice Address - Fax:310-582-7140
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57490208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G574900Medicaid
CAWG57490AMedicare ID - Type Unspecified
CA00G574900Medicaid