1659364263 NPI number — GREGORY STEPHAN WILSON MD

Table of content: GREGORY STEPHAN WILSON MD (NPI 1659364263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659364263 NPI number — GREGORY STEPHAN WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
GREGORY
Provider Middle Name:
STEPHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1659364263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 SOUTH NOLAN RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEBURNE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76033-6501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-517-9466
Provider Business Mailing Address Fax Number:
817-556-9156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 SOUTH NOLAN RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEBURNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76033-6501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-517-9466
Provider Business Practice Location Address Fax Number:
817-556-9156
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G0293 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00DR73 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 121512101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121512104 . This is a "TEXAS MEDICAID THSTP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1029775 . This is a "AMERIGROUP TEXAS, INC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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