Provider Demographics
NPI:1285638999
Name:WILSON, GLEN P (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:P
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 1:4901 LANG AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4495
Mailing Address - Country:US
Mailing Address - Phone:505-842-8171
Mailing Address - Fax:505-857-3877
Practice Address - Street 1:4901 LANG AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4495
Practice Address - Country:US
Practice Address - Phone:505-842-8171
Practice Address - Fax:505-857-3877
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000-3142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM700521102OtherMEDICARE GROUP
NML0634Medicaid
NM45138Medicaid
NM600521002OtherMEDICARE IDTF
NM2258272OtherMEDICARE GROUP
NM66463Medicaid
NM800521126OtherMEDICARE IDTF
NM52713Medicaid
NM52713Medicaid
NM45138Medicaid