Provider Demographics
NPI:1609309566
Name:VILSON, FERNANDINO LOUIS (MD)
Entity type:Individual
Prefix:
First Name:FERNANDINO
Middle Name:LOUIS
Last Name:VILSON
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 1:400 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:240-566-7754
Practice Address - Street 1:1562 OPOSSUMTOWN PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4920
Practice Address - Country:US
Practice Address - Phone:240-215-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01094508A208800000X
MDD0100975208800000X
MO2023010472208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200121997Medicaid
IN224040220OtherMEDICARE PTAN