Provider Demographics
NPI:1447666821
Name:WILSON INTERNAL MEDICINE, LLC
Entity type:Organization
Organization Name:WILSON INTERNAL MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-646-9429
Mailing Address - Street 1:640 ULUKAHIKI ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4454
Mailing Address - Country:US
Mailing Address - Phone:808-263-5174
Mailing Address - Fax:808-266-3614
Practice Address - Street 1:640 ULUKAHIKI ST
Practice Address - Street 2:SUITE 103
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4454
Practice Address - Country:US
Practice Address - Phone:808-263-5174
Practice Address - Fax:808-266-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-12951207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty