Provider Demographics
NPI:1568424687
Name:WILLIAM L. WILSON, M.D., INC.
Entity Type:Organization
Organization Name:WILLIAM L. WILSON, M.D., INC.
Other - Org Name:CALIFORNIA PAIN AND SPINE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BROWNLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-252-7557
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG. 3, STE. 540
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-460-2700
Mailing Address - Fax:619-460-2702
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG. 3, STE. 540
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-460-2700
Practice Address - Fax:619-460-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44872208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G448720Medicaid
CA00G448721Medicaid
CAA49788Medicare UPIN
CA00G448720Medicaid