Provider Demographics
NPI:1760433247
Name:WILSON, BRIAN GUY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GUY
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:PO BOX 13058
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-3058
Mailing Address - Country:US
Mailing Address - Phone:850-656-7720
Mailing Address - Fax:850-656-7729
Practice Address - Street 1:2619 CENTENNIAL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0590
Practice Address - Country:US
Practice Address - Phone:850-656-7720
Practice Address - Fax:850-656-7729
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.15516R207KA0200X
FLME82516207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2622203Medicaid
H47012Medicare UPIN
FL00003005ZMedicare ID - Type Unspecified