Provider Demographics
NPI:1083077507
Name:WILSON, ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2546 SW 74TH TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7028
Mailing Address - Country:US
Mailing Address - Phone:954-475-5758
Mailing Address - Fax:
Practice Address - Street 1:1725 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2249
Practice Address - Country:US
Practice Address - Phone:251-943-2141
Practice Address - Fax:251-943-2846
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.1832207V00000X
FLOS21802207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL253585Medicaid
AL252633Medicaid