Provider Demographics
NPI:1760430953
Name:WILSON, STEPHEN E (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
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 1:11550 WINTON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-2355
Mailing Address - Country:US
Mailing Address - Phone:513-924-8200
Mailing Address - Fax:513-924-8201
Practice Address - Street 1:11550 WINTON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-2355
Practice Address - Country:US
Practice Address - Phone:513-924-8200
Practice Address - Fax:513-924-8201
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-078262207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00919598OtherMEDICARE RR
IN200391060Medicaid
OH2357079Medicaid
OH2357079Medicaid
H67024Medicare UPIN
KY64056054Medicare ID - Type Unspecified