Provider Demographics
NPI:1982794293
Name:WILSON, TIMOTHY L (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2825 E BARNETT RD
Mailing Address - Street 2:MSS
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-4806
Practice Address - Street 1:781 BLACK OAK DR #102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9501
Practice Address - Country:US
Practice Address - Phone:541-789-4236
Practice Address - Fax:541-789-5965
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR20004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA94205Medicare UPIN