Provider Demographics
NPI:1619421674
Name:DAVID E WILSON MD LLC
Entity Type:Organization
Organization Name:DAVID E WILSON MD LLC
Other - Org Name:DAVID E WILSON MD LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-804-5223
Mailing Address - Street 1:190 NE 91ST ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-3329
Mailing Address - Country:US
Mailing Address - Phone:816-804-5223
Mailing Address - Fax:
Practice Address - Street 1:190 NE 91ST ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-3329
Practice Address - Country:US
Practice Address - Phone:816-804-5223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110042554OtherRAILROAD MEDICARE
MO04489010OtherBLUE CROSS OF KANSAS CITY INDIVIDUAL#
MO110042554OtherRAILROAD MEDICARE
MOC50900Medicare UPIN