Provider Demographics
NPI:1962842476
Name:WILSON, PHILIP JOSEPH III (DO)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:JOSEPH
Last Name:WILSON
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:PHILIP
Other - Middle Name:JOSEPH
Other - Last Name:WILSON
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1241 W. STADIUM BLVD.
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6023
Mailing Address - Country:US
Mailing Address - Phone:573-556-7709
Mailing Address - Fax:573-556-1709
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7709
Practice Address - Fax:573-556-1709
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021706207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200029781Medicaid