Provider Demographics
NPI:1184647091
Name:WILSON, BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
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:PO BOX 6089
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-6089
Mailing Address - Country:US
Mailing Address - Phone:888-398-1370
Mailing Address - Fax:
Practice Address - Street 1:1303 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3309
Practice Address - Country:US
Practice Address - Phone:559-450-3205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84254207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA84254OtherBLUE CROSS
A84254OtherCOUNTY OF FRESNO
CA00A842540OtherBLUE SHIELD
CA00A842540Medicaid
CA00A842540Medicaid
CR0087Medicare PIN
00A842541Medicare PIN
A84254OtherCOUNTY OF FRESNO
P00387044Medicare PIN