Provider Demographics
NPI:1912948019
Name:WILSON, SAMUEL G (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
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 1:12021 JACARANDA AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4978
Mailing Address - Country:US
Mailing Address - Phone:760-956-5057
Mailing Address - Fax:760-948-2179
Practice Address - Street 1:12021 JACARANDA AVE
Practice Address - Street 2:101
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-4956
Practice Address - Country:US
Practice Address - Phone:760-956-5057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55580207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G555800Medicaid
CA00G555800Medicare ID - Type Unspecified
CA00G555800Medicaid