Provider Demographics
NPI:1992715296
Name:WILSON, KEVIN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3300 HIGH ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3321
Mailing Address - Country:US
Mailing Address - Phone:757-399-4341
Mailing Address - Fax:757-393-0743
Practice Address - Street 1:3300 HIGH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3321
Practice Address - Country:US
Practice Address - Phone:757-399-4341
Practice Address - Fax:757-393-0743
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101035314207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA027301OtherANTHEM BC BS
VA22116OtherOPTIMA HEALTH
VAB07964Medicare UPIN