Provider Demographics
NPI:1366705766
Name:WILSON, DINA (DO)
Entity type:Individual
Prefix:DR
First Name:DINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 6TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1916
Mailing Address - Country:US
Mailing Address - Phone:541-812-3349
Mailing Address - Fax:541-812-3342
Practice Address - Street 1:1046 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1916
Practice Address - Country:US
Practice Address - Phone:541-812-3349
Practice Address - Fax:541-812-3342
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO171954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine