Provider Demographics
NPI:1265686281
Name:WILSON, PHILLIP EGBERT (MD, PHD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EGBERT
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 10TH AVE STE 154
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2876
Mailing Address - Country:US
Mailing Address - Phone:801-408-8500
Mailing Address - Fax:
Practice Address - Street 1:324 10TH AVE STE 154
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2876
Practice Address - Country:US
Practice Address - Phone:801-408-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7471471-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry