Provider Demographics
NPI:1528018595
Name:WILSON, BRIAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:275 PONAHAWAI ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3074
Mailing Address - Country:US
Mailing Address - Phone:808-961-0022
Mailing Address - Fax:808-969-3852
Practice Address - Street 1:275 PONAHAWAI ST
Practice Address - Street 2:SUITE 106
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3074
Practice Address - Country:US
Practice Address - Phone:808-961-0022
Practice Address - Fax:808-969-3852
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HI41432080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04734301Medicaid
HIE5377-6Medicare UPIN