Provider Demographics
NPI:1457732000
Name:WILLIAM WILSON MD PC
Entity Type:Organization
Organization Name:WILLIAM WILSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:208-524-4381
Mailing Address - Street 1:2860 CHANNING WAY STE 112
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7532
Mailing Address - Country:US
Mailing Address - Phone:208-524-4381
Mailing Address - Fax:208-523-6477
Practice Address - Street 1:2860 CHANNING WAY STE 112
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7532
Practice Address - Country:US
Practice Address - Phone:208-524-4381
Practice Address - Fax:208-523-6477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM 55272082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty