Provider Demographics
NPI:1134315005
Name:BRIAN WILSON MD L.L.C.
Entity Type:Organization
Organization Name:BRIAN WILSON MD L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-961-0022
Mailing Address - Street 1:275 PONAHAWAI ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3074
Mailing Address - Country:US
Mailing Address - Phone:808-961-0022
Mailing Address - Fax:808-969-3852
Practice Address - Street 1:275 PONAHAWAI ST
Practice Address - Street 2:SUITE 106
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3074
Practice Address - Country:US
Practice Address - Phone:808-961-0022
Practice Address - Fax:808-969-3852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI41432080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA04734301Medicaid