Provider Demographics
NPI:1265433866
Name:WILSON, RICHARD ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
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 1:885 MISSION STREET SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-585-5585
Mailing Address - Fax:503-587-7823
Practice Address - Street 1:885 MISSION STREET SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-585-5585
Practice Address - Fax:503-587-7823
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13790207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR060046918OtherRAILROAD MEDICARE
OR286138Medicaid
ORC94093Medicare UPIN
OR100429Medicare PIN