Provider Demographics
NPI:1487613402
Name:WILSON, TIMOTHY R (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11768
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-0168
Mailing Address - Country:US
Mailing Address - Phone:804-353-4000
Mailing Address - Fax:804-213-9783
Practice Address - Street 1:300 71ST STREET
Practice Address - Street 2:SUITE 620
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-3089
Practice Address - Country:US
Practice Address - Phone:305-866-9951
Practice Address - Fax:877-284-8933
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C05516OtherMEDICARE GROUP NUMBER
VA010199824Medicaid
VA010199824Medicaid
I44417Medicare UPIN