Individual
ETHAN WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
11301 WILSHIRE BLVD, LOS ANGELES, CA 90073-1003
(310) 478-3711
Mailing address
11301 WILSHIRE BLVD, LOS ANGELES, CA 90073-1003
(310) 478-3711
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
125.083306
IL
208100000X
Physical Medicine & Rehabilitation Physician
Primary
125.083306
CA
390200000X
Student in an Organized Health Care Education/Training Program
125.083306
IL
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
03/08/2023
Last updated
06/06/2025
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