Provider Demographics
NPI:1659364263
Name:WILSON, GREGORY STEPHAN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:STEPHAN
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 1:1001 SOUTH NOLAN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-6501
Mailing Address - Country:US
Mailing Address - Phone:817-517-9466
Mailing Address - Fax:817-556-9156
Practice Address - Street 1:1001 SOUTH NOLAN RIVER RD
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-6501
Practice Address - Country:US
Practice Address - Phone:817-517-9466
Practice Address - Fax:817-556-9156
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00DR73OtherBLUE CROSS BLUE SHIELD
TX121512101Medicaid
TX121512104OtherTEXAS MEDICAID THSTP
TX1029775OtherAMERIGROUP TEXAS, INC
TX00DR73OtherBLUE CROSS BLUE SHIELD
TX00DR73Medicare PIN