Provider Demographics
NPI:1902838105
Name:WILSON, PAUL STUART (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:STUART
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 1:1666 E BERT KOUN LOOP STE 105
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5718
Mailing Address - Country:US
Mailing Address - Phone:318-212-3520
Mailing Address - Fax:318-212-3525
Practice Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP STE 105
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5718
Practice Address - Country:US
Practice Address - Phone:318-212-3520
Practice Address - Fax:318-212-3525
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.020189207RA0401X
LA020189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1911879Medicaid
LA5H067Medicare PIN
E80813Medicare UPIN
LA5H067DE77Medicare PIN
LA1911879Medicaid