Provider Demographics
NPI:1225025935
Name:WILSON, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:WILSON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1000 BRECKENRIDGE ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-0878
Mailing Address - Country:US
Mailing Address - Phone:270-691-8050
Mailing Address - Fax:270-691-8051
Practice Address - Street 1:1000 BRECKENRIDGE ST
Practice Address - Street 2:SUITE 404
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-0878
Practice Address - Country:US
Practice Address - Phone:270-691-8050
Practice Address - Fax:270-691-8051
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2019-05-02
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Provider Licenses
StateLicense IDTaxonomies
KY42171207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100065360Medicaid
KY000000588181OtherBCBS PIN#
KY7100065360Medicaid