Provider Demographics
NPI:1114902327
Name:WILSON, PHILIP J II (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
Last Name:WILSON
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-7709
Mailing Address - Fax:573-556-1709
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7709
Practice Address - Fax:573-556-1709
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-08-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR6C26207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241745801Medicaid
MO9218OtherBCBS
MO180032824OtherMEDICARE RAILROAD
MO106914OtherHEALTHLINK
MOCP9089OtherRAILROAD GROUP
MO180032824OtherMEDICARE RAILROAD
MO003012494Medicare PIN