Provider Demographics
NPI:1285693572
Name:WILSON, DOUGLAS RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:RICHARD
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 1:1100 TRANCAS ST STE 300
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2921
Mailing Address - Country:US
Mailing Address - Phone:707-254-1770
Mailing Address - Fax:707-254-1779
Practice Address - Street 1:1141 PEAR TREE LANE
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6485
Practice Address - Country:US
Practice Address - Phone:707-254-1770
Practice Address - Fax:707-254-1779
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71642207QH0002X, 207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A716420Medicaid
H45937Medicare UPIN
00A716422Medicare ID - Type Unspecified