Provider Demographics
NPI:1730183344
Name:WILSON, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N MONTEBELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2584
Mailing Address - Country:US
Mailing Address - Phone:714-478-2253
Mailing Address - Fax:323-889-7819
Practice Address - Street 1:1401 N MONTEBELLO BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2584
Practice Address - Country:US
Practice Address - Phone:714-478-2253
Practice Address - Fax:323-889-7819
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49347207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G493470OtherMEDI CAL #
CA00G493470OtherMEDI CAL #