Provider Demographics
NPI:1669653499
Name:STEPHEN L WILSON MD PA
Entity Type:Organization
Organization Name:STEPHEN L WILSON MD PA
Other - Org Name:WESTERN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORRAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-870-1035
Mailing Address - Street 1:1015 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2924
Mailing Address - Country:US
Mailing Address - Phone:817-870-1035
Mailing Address - Fax:817-332-5005
Practice Address - Street 1:1015 S HENDERSON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2924
Practice Address - Country:US
Practice Address - Phone:817-870-1035
Practice Address - Fax:817-332-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00737NMedicare PIN