Provider Demographics
NPI:1174633085
Name:WILSON, KEVIN WILLIAM (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-5400
Mailing Address - Fax:208-302-5455
Practice Address - Street 1:5966 W CURTISIAN AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-5400
Practice Address - Fax:208-302-5455
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1071207R00000X
AZ2688207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ110388Medicaid
F29970Medicare UPIN
AZ110388Medicaid