Individual
IVY WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
17 DAVIS BLVD STE 308, TAMPA, FL 33606-3438
(813) 974-2201
Mailing address
17 DAVIS BLVD STE 308, TAMPA, FL 33606-3438
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
ME162142
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
118623300
—
FL
01
—
M1I8C
BLUE CROSS BLUE SHIELD
FL
Enumeration date
04/09/2020
Last updated
07/17/2023
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