Provider Demographics
NPI:1225023096
Name:WILSON, LENNARD STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:LENNARD
Middle Name:STEVEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6520 DRIFTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-3218
Mailing Address - Country:US
Mailing Address - Phone:406-251-5253
Mailing Address - Fax:406-251-6153
Practice Address - Street 1:2835 FORT MISSOULA RD
Practice Address - Street 2:STE 203
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7423
Practice Address - Country:US
Practice Address - Phone:406-327-4091
Practice Address - Fax:406-327-4590
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2021-04-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MT67492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0088049Medicaid
MTD41411Medicare UPIN
MT0088049Medicaid