Provider Demographics
NPI:1558388025
Name:WILSON, KENNETH M (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:M
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:PO BOX 1168
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-1168
Mailing Address - Country:US
Mailing Address - Phone:936-777-2255
Mailing Address - Fax:
Practice Address - Street 1:700 BELLEVUE ST SE
Practice Address - Street 2:SUITE 260
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3819
Practice Address - Country:US
Practice Address - Phone:503-375-3636
Practice Address - Fax:503-375-3737
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD162172086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR045336Medicaid
OR045336Medicaid
133332Medicare PIN
E79234Medicare UPIN