Provider Demographics
NPI:1952499931
Name:WILSON, BENJAMIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:R
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 1:700 BELLEVUE ST SE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-399-0644
Mailing Address - Fax:503-581-5351
Practice Address - Street 1:700 BELLEVUE ST SE
Practice Address - Street 2:SUITE 240
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-399-0644
Practice Address - Fax:503-581-5351
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12349208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR159657Medicaid
C94087Medicare UPIN
OR159657Medicaid