Provider Demographics
NPI:1063402840
Name:WILSON, GOLDER N (MD)
Entity type:Individual
Prefix:
First Name:GOLDER
Middle Name:N
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:MS 9406
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-7337
Practice Address - Fax:806-743-7329
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5095208000000X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119194212Medicaid
TX127048101OtherFIRSTCARE COMMERCIAL
TX119194205Medicaid
TX8H8760OtherBC/BS
TX119194204Medicaid
TX119194211Medicaid
TX127048102Medicaid
TX87286ZOtherHMO BLUE
TXY0069496OtherDPS
NMA562OtherTRIWEST
NM82994OtherPRESBYTERIAN COMMERCIAL
NM82994Medicaid
OK100056830 AMedicaid
TX119194216Medicaid
NM31405762Medicaid
TXAW6518914OtherDEA
TXAW6518914OtherDEA
TX8H8760OtherBC/BS
NM31405762Medicaid
NM82994Medicaid
TX8L25638Medicare PIN