Provider Demographics
NPI:1548291081
Name:WILSON, STEVEN (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
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 1:1201 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4402
Mailing Address - Country:US
Mailing Address - Phone:909-798-6524
Mailing Address - Fax:909-792-0858
Practice Address - Street 1:1201 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4402
Practice Address - Country:US
Practice Address - Phone:909-798-6524
Practice Address - Fax:909-792-0858
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46504174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0743773OtherCORP. TAX ID NUMBER
CAE83044Medicare UPIN
CA33-0743773OtherCORP. TAX ID NUMBER