Provider Demographics
NPI:1396092219
Name:WILSON, GEORGE M (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:M
Other - Last Name:WILSON
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-857-5650
Mailing Address - Fax:701-857-5031
Practice Address - Street 1:1321 W DAKOTA PKWY
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3807
Practice Address - Country:US
Practice Address - Phone:701-572-7711
Practice Address - Fax:701-572-2283
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine