Provider Demographics
NPI:1578598173
Name:WILSON, TIMOTHY S (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 N KUAKINI ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2336
Mailing Address - Country:US
Mailing Address - Phone:808-536-2236
Mailing Address - Fax:808-547-9547
Practice Address - Street 1:347 N KUAKINI ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2336
Practice Address - Country:US
Practice Address - Phone:808-536-2236
Practice Address - Fax:808-547-9547
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS 1192207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI61186501Medicaid