Provider Demographics
NPI:1992728620
Name:WILSON, VANESSA VALENCIA (MD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:VALENCIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39141 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5818
Mailing Address - Country:US
Mailing Address - Phone:510-248-1680
Mailing Address - Fax:510-792-2499
Practice Address - Street 1:38719 STIVERS ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5337
Practice Address - Country:US
Practice Address - Phone:510-248-1000
Practice Address - Fax:510-608-6055
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA049261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A492610Medicare ID - Type Unspecified
CAE71820Medicare UPIN