Provider Demographics
NPI:1992988612
Name:WILSON, MITCHELL DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:DAVID
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 1:2960 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2344
Mailing Address - Country:US
Mailing Address - Phone:510-843-4660
Mailing Address - Fax:510-843-4675
Practice Address - Street 1:2960 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2344
Practice Address - Country:US
Practice Address - Phone:510-843-4660
Practice Address - Fax:510-843-4675
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG564562084P0800X
102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst