Provider Demographics
NPI:1952441339
Name:WILSON, WARREN T (DO)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:T
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-819 LAUNAHELE ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-4753
Mailing Address - Country:US
Mailing Address - Phone:417-839-6517
Mailing Address - Fax:
Practice Address - Street 1:91-819 LAUNAHELE ST
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-4753
Practice Address - Country:US
Practice Address - Phone:417-839-6517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9934207Q00000X
HI2404207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO9736OtherMO BLUE SHIELD
MO241145903Medicaid
AR82518OtherARK BLUE SHIELD
MO138013268Medicare PIN
MO241145903Medicaid