Provider Demographics
NPI:1033182118
Name:WILSON, WANDA GAYLE (DO)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:GAYLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:VLAHOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3559 AMAZONAS ST
Mailing Address - Street 2:HEALTH BRANCH WEST
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109
Mailing Address - Country:US
Mailing Address - Phone:573-893-7848
Mailing Address - Fax:573-893-1984
Practice Address - Street 1:3559 AMAZONAS ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-893-7848
Practice Address - Fax:573-893-1984
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8779208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
9183317004OtherCIGNA
P00200365OtherRR MEDICARE
185418OtherBCBS
MO241488329Medicaid
829180OtherFIRST HEALTH
D41738OtherMERCY
251463OtherHEALTHLINK
9183317004OtherCIGNA
D41738Medicare UPIN