1679502918 NPI number — DR. DOUGLAS A WILSON MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679502918 NPI number — DR. DOUGLAS A WILSON MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WILSON

Provider First Name:

DOUGLAS

Provider Middle Name:

A

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1679502918

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 2847

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CORVALLIS

Provider Business Mailing Address State Name:

OR

Provider Business Mailing Address Postal Code:

97339-2847

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

930 SW ABBEY ST STE B

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

NEWPORT

Provider Business Practice Location Address State Name:

OR

Provider Business Practice Location Address Postal Code:

97365-4820

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

541-574-7235

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

06/30/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208600000X , with the licence number:  4301056816 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208600000X , with the licence number: M10679 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208600000X , with the licence number: MD157658 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 77943 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
• Identifier: 808373700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 0249855 . This is a "WASHINGTON LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 1679502918 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
• Identifier: 000010173389 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
• Identifier: 0201174022 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 1679502918 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
• Identifier: 20039075 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".