Provider Demographics
NPI:1437215340
Name:WILSON, GAYLE RAY (MD)
Entity Type:Individual
Prefix:MR
First Name:GAYLE
Middle Name:RAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:G
Other - Middle Name:R
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338
Mailing Address - Country:US
Mailing Address - Phone:503-623-8826
Mailing Address - Fax:503-623-8739
Practice Address - Street 1:289 E ELLENDALE
Practice Address - Street 2:SUITE 503
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338
Practice Address - Country:US
Practice Address - Phone:503-623-8826
Practice Address - Fax:503-623-8739
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09317207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004460Medicaid
OR004460Medicaid
0000RIBAFMedicare ID - Type Unspecified