Provider Demographics
NPI:1972587350
Name:WILSON, RICHARD C (DPM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2946
Mailing Address - Country:US
Mailing Address - Phone:321-723-3500
Mailing Address - Fax:321-723-1945
Practice Address - Street 1:1515 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2946
Practice Address - Country:US
Practice Address - Phone:321-723-3500
Practice Address - Fax:321-723-1945
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO421213E00000X
IL016003144213E00000X
FLPO1322213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041009800Medicaid
FL87733OtherBCBS
T55522Medicare UPIN