Provider Demographics
NPI:1831121938
Name:WILSON, BRENT DONALD (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DONALD
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, PHD
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-408-8112
Mailing Address - Fax:801-408-6830
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:ROOM 4A100 SOM
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-585-7676
Practice Address - Fax:801-581-7735
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4984011-1205207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000061047Medicare PIN
UT000063699Medicare PIN
UTI54731Medicare UPIN