Provider Demographics
NPI:1871572404
Name:WILSON, BRIAN PATRICK (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
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 1:1823 HIGHWAY BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-2226
Mailing Address - Country:US
Mailing Address - Phone:712-262-6320
Mailing Address - Fax:712-264-3007
Practice Address - Street 1:1823 HIGHWAY BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-2226
Practice Address - Country:US
Practice Address - Phone:712-262-6320
Practice Address - Fax:712-264-3007
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03049207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0250886Medicaid
IAH53095Medicare UPIN
IA0250886Medicaid