Provider Demographics
NPI:1821055211
Name:WILSON, STANLEY J (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5005 DOGWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-8900
Mailing Address - Country:US
Mailing Address - Phone:660-827-2883
Mailing Address - Fax:660-827-1359
Practice Address - Street 1:3401 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2112
Practice Address - Country:US
Practice Address - Phone:660-827-2883
Practice Address - Fax:660-827-1359
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36325207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201709516Medicaid
MOC50853Medicare UPIN
MO201709516Medicaid