Provider Demographics
NPI:1700980042
Name:WILSON, FREDRICK SAUL (DPM)
Entity type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:SAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 MOWRY AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1737
Mailing Address - Country:US
Mailing Address - Phone:510-796-2191
Mailing Address - Fax:510-796-2250
Practice Address - Street 1:1895 MOWRY AVE
Practice Address - Street 2:STE 103
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1737
Practice Address - Country:US
Practice Address - Phone:510-796-2191
Practice Address - Fax:510-796-2250
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2105213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E21050Medicare ID - Type Unspecified
CA5159800001Medicare NSC
T11178Medicare UPIN