Provider Demographics
NPI:1245301084
Name:WILSON, STEPHEN M (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
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 1:1950 SUNNY CREST DR STE 2600
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3644
Mailing Address - Country:US
Mailing Address - Phone:714-446-5260
Mailing Address - Fax:
Practice Address - Street 1:1950 SUNNYCREST DR
Practice Address - Street 2:SUITE 2600
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3638
Practice Address - Country:US
Practice Address - Phone:714-446-5260
Practice Address - Fax:714-446-5265
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23030174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAS964ZMedicare PIN
CAW536Medicare ID - Type Unspecified