Provider Demographics
NPI:1952653149
Name:WILSON, DAVID LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEROY
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 1:2890 NE JACKSON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-1615
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:
Practice Address - Street 1:2890 NE JACKSON SCHOOL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-1615
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD29271207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology