Provider Demographics
NPI:1447487665
Name:WILSON, DANICA EDRIRE JOI (MD)
Entity type:Individual
Prefix:DR
First Name:DANICA
Middle Name:EDRIRE JOI
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 W WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-5020
Mailing Address - Country:US
Mailing Address - Phone:313-719-0161
Mailing Address - Fax:
Practice Address - Street 1:7531 S STONY ISLAND AVE STE 152
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3954
Practice Address - Country:US
Practice Address - Phone:313-719-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.130830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine