Provider Demographics
NPI:1275777351
Name:W. BRUCE WILSON, MD PC
Entity Type:Organization
Organization Name:W. BRUCE WILSON, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:W.
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:303-733-5333
Mailing Address - Street 1:850 E. HARVARD AVE.
Mailing Address - Street 2:SUITE 355
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5033
Mailing Address - Country:US
Mailing Address - Phone:303-733-5333
Mailing Address - Fax:303-733-5386
Practice Address - Street 1:850 E. HARVARD AVE.
Practice Address - Street 2:SUITE 355
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5033
Practice Address - Country:US
Practice Address - Phone:303-733-5333
Practice Address - Fax:303-733-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16962174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01169622Medicaid
CO01169622Medicaid
COC97271Medicare PIN