Provider Demographics
NPI:1871109827
Name:WILSON T ASFORA MD FRCSC PC
Entity type:Organization
Organization Name:WILSON T ASFORA MD FRCSC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-646-9797
Mailing Address - Street 1:2601 S. MINNESOTA AVENUE
Mailing Address - Street 2:SUITE 105 MB385
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:305-646-9797
Mailing Address - Fax:305-921-9682
Practice Address - Street 1:6709 S MINNESOTA AVE STE 206A
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2593
Practice Address - Country:US
Practice Address - Phone:305-646-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1336355379Medicaid