Provider Demographics
NPI:1679797260
Name:WILSON, DOUGLAS GLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GLEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-348-8000
Practice Address - Fax:573-348-8309
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADO.000244207P00000X
MO2014017392207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine