Provider Demographics
NPI:1467434969
Name:WILSON, STEWART M JR (MD)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:M
Last Name:WILSON
Suffix:JR
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 1:341 MEDICAL LOOP, SUITE 120
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-5575
Mailing Address - Country:US
Mailing Address - Phone:541-672-8288
Mailing Address - Fax:
Practice Address - Street 1:341 MEDICAL LOOP
Practice Address - Street 2:STE 120
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5546
Practice Address - Country:US
Practice Address - Phone:541-672-8288
Practice Address - Fax:541-672-0665
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08850207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213629Medicaid
C91073Medicare UPIN
OR213629Medicaid