Provider Demographics
NPI:1639371966
Name:WILSON, WEBB CLANTON (DO)
Entity Type:Individual
Prefix:
First Name:WEBB
Middle Name:CLANTON
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:PO BOX 14001
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-5014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 BELLEVUE ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-814-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20700000X207P00000X
ORDO157451207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0026737OtherINSTITUTIONAL PERMIT
TN2012OtherTENNESSEE MEDICAL LICENSE
TXM8432OtherTEXAS MEDICAL LICENSE