Provider Demographics
NPI:1023034725
Name:WILSON, DOUGLAS LEE (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:5383 HOLLISTER AVE STE 160
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93111-2357
Practice Address - Country:US
Practice Address - Phone:805-565-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8387128Medicaid
WAP01288328OtherRR MEDICARE
WA0183784OtherL&I
WA0183784OtherL&I
WA8802122Medicare ID - Type Unspecified
WA8387128Medicaid