Provider Demographics
NPI:1447368758
Name:WILSON, WILLIAM PD III (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:PD
Last Name:WILSON
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:2860 CHANNING WAY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-524-4381
Mailing Address - Fax:208-523-6477
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 112
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-524-4381
Practice Address - Fax:208-523-6477
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2015-02-20
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Provider Licenses
StateLicense IDTaxonomies
IDM-5527208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
EO7079Medicare UPIN