Provider Demographics
NPI:1174578744
Name:WILSON, DEBORAH YVONNE (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:YVONNE
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 1:6510 KENILWORTH AVE
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1339
Mailing Address - Country:US
Mailing Address - Phone:301-699-1882
Mailing Address - Fax:301-209-9456
Practice Address - Street 1:6510 KENILWORTH AVE
Practice Address - Street 2:SUITE 1300
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1339
Practice Address - Country:US
Practice Address - Phone:301-699-1882
Practice Address - Fax:301-209-9456
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2007-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0050068207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE31630Medicare UPIN