Provider Demographics
NPI:1730152992
Name:WILSON, GARY E (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11373 CORTEZ BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5414
Mailing Address - Country:US
Mailing Address - Phone:352-597-9095
Mailing Address - Fax:352-597-1446
Practice Address - Street 1:11373 CORTEZ BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5414
Practice Address - Country:US
Practice Address - Phone:352-597-9095
Practice Address - Fax:352-597-1446
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME16628208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53429Medicare UPIN
FL20619Medicare ID - Type UnspecifiedMEDICARE NUMBER