Provider Demographics
NPI:1841262045
Name:WILLSON, STUART L (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:L
Last Name:WILLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1136 W 6TH ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1805
Mailing Address - Country:US
Mailing Address - Phone:213-977-1144
Mailing Address - Fax:213-482-2182
Practice Address - Street 1:1136 W 6TH ST
Practice Address - Street 2:SUITE 307
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1805
Practice Address - Country:US
Practice Address - Phone:213-977-1144
Practice Address - Fax:213-482-2182
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG52677207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG52677AMedicare ID - Type Unspecified
CAA52320Medicare UPIN