Provider Demographics
NPI:1265787303
Name:GREGORY B. WILSON, M.D., INC.
Entity type:Organization
Organization Name:GREGORY B. WILSON, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-735-9093
Mailing Address - Street 1:1329 LUSITANA ST
Mailing Address - Street 2:SUITE 604
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2429
Mailing Address - Country:US
Mailing Address - Phone:808-531-1116
Mailing Address - Fax:
Practice Address - Street 1:1329 LUSITANA ST
Practice Address - Street 2:SUITE 604
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2429
Practice Address - Country:US
Practice Address - Phone:808-531-1116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-03515207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04569301Medicaid
HI00A0051910OtherHMSA