Active NPI
Mitchell David Wilson, M.D.
- Psychiatry Physician
- Berkeley, CA
National Provider Identifier
1992988612
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- G56456
- Practice address
- 2960 Piedmont Ave
Berkeley, CA 94705-2344 - Phone
- (510) 843-4660
- Fax
- (510) 843-4675
- NPI assigned
- Dec 17, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | G56456 | CA | Primary |
| Psychoanalyst | 102L00000X |
Addresses
Primary practice location
2960 Piedmont Ave
Berkeley, CA 94705-2344
Mailing address
2960 Piedmont Ave
Berkeley, CA 94705-2344
Phone (510) 843-4660
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Feb 2, 2016 through Feb 2, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 56456 | CA | MD | Pharmacotherapy Pharmacist |
| G56456 | CA | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1197849600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1197936000000",
"number": "1992988612",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2960 PIEDMONT AVE",
"city": "BERKELEY",
"state": "CA",
"postal_code": "947052344",
"telephone_number": "510-843-4660",
"fax_number": "510-843-4675"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2960 PIEDMONT AVE",
"city": "BERKELEY",
"state": "CA",
"postal_code": "947052344",
"telephone_number": "510-843-4660",
"fax_number": "510-843-4675"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "MITCHELL",
"middle_name": "DAVID",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-12-17",
"last_updated": "2007-12-18",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "CA",
"license": "G56456",
"primary": true
},
{
"code": "102L00000X",
"taxonomy_group": "",
"desc": "Psychoanalyst",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Berkeley, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.