Provider Demographics
NPI:1366050361
Name:WILSON, IRIS MIGDALIA (MD)
Entity type:Individual
Prefix:DR
First Name:IRIS
Middle Name:MIGDALIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 W COLONIAL DR STE 303
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6863
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:1502 VILLAGE OAK LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-6558
Practice Address - Country:US
Practice Address - Phone:407-520-3588
Practice Address - Fax:407-978-6757
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21972208D00000X
PR15150208D00000X
FLACN1344208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111941200Medicaid