Provider Demographics
NPI:1811174154
Name:WILSON, GREGORY TODD (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:TODD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:
Practice Address - Street 1:140 N POINTE BLVD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4132
Practice Address - Country:US
Practice Address - Phone:717-291-0700
Practice Address - Fax:717-207-8626
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-013977207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102143480Medicaid
PA128372Medicare PIN