Provider Demographics
NPI:1689899981
Name:WILSON, HEATHER LEE (DPM)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15815 SHADDOCK DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5773
Mailing Address - Country:US
Mailing Address - Phone:407-605-2321
Mailing Address - Fax:407-671-4155
Practice Address - Street 1:5741 BEE RIDGE RD STE 490
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-5062
Practice Address - Country:US
Practice Address - Phone:941-924-8777
Practice Address - Fax:941-924-5888
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300729213ES0103X
FLPO4606213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU76405Medicare UPIN