Provider Demographics
NPI:1659372746
Name:WILSON, PAUL WESLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WESLEY
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 8440
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-0440
Mailing Address - Country:US
Mailing Address - Phone:419-885-0200
Mailing Address - Fax:419-885-0203
Practice Address - Street 1:440 S REYNOLDS RD
Practice Address - Street 2:STE. B
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-5934
Practice Address - Country:US
Practice Address - Phone:419-819-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-002939W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0432384Medicaid
OH0484607Medicare PIN
OH0432384Medicaid