Provider Demographics
NPI:1922636265
Name:WILSON, COURTNEY MEREDITH
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MEREDITH
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 W HOLCOMBE BLVD FL 6
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3306
Mailing Address - Country:US
Mailing Address - Phone:713-563-2772
Mailing Address - Fax:
Practice Address - Street 1:2130 W HOLCOMBE BLVD FL 6
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3306
Practice Address - Country:US
Practice Address - Phone:713-563-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10088608207ND0101X
OH35.153183207ND0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program