Provider Demographics
NPI:1295826857
Name:WILSON, BRUCE EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDWARD
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 1:925 STEVENS DR STE 2E
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3523
Mailing Address - Country:US
Mailing Address - Phone:509-940-9052
Mailing Address - Fax:590-542-8095
Practice Address - Street 1:925 STEVENS DR STE 2E
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3523
Practice Address - Country:US
Practice Address - Phone:509-940-9052
Practice Address - Fax:590-940-9054
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0023055207RE0101X
WAMD00023055207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0023055OtherSTATE LICENSE
WA121374Medicaid
WA121374Medicaid