Provider Demographics
NPI:1538152400
Name:WILSON, DIANA ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:ELIZABETH
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 1:1001 12TH AVE STE 171
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3926
Mailing Address - Country:US
Mailing Address - Phone:817-576-6500
Mailing Address - Fax:682-703-2064
Practice Address - Street 1:1001 12TH AVE STE 171
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-576-6500
Practice Address - Fax:682-703-2064
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0729207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162405801Medicaid
TX129595807Medicaid
TX8B2830Medicare ID - Type Unspecified
TX8L13600Medicare PIN
TX129595807Medicaid