Provider Demographics
NPI:1871593764
Name:WILSON, CARMEN JOSEFA (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:JOSEFA
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:PO BOX 162264
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-2264
Mailing Address - Country:US
Mailing Address - Phone:941-792-2020
Mailing Address - Fax:
Practice Address - Street 1:820 W SUGARLAND HWY
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440
Practice Address - Country:US
Practice Address - Phone:941-792-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044609207W00000X
FLME140321207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000791249BMedicaid
GA1871593764Medicare UPIN
GA000791249BMedicaid