Provider Demographics
NPI:1932272812
Name:WILSON, GREGORY B (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:B
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 1:1329 LUSITANA ST STE 604
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2431
Mailing Address - Country:US
Mailing Address - Phone:808-735-9093
Mailing Address - Fax:
Practice Address - Street 1:1329 LUSITANA ST STE 604
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2431
Practice Address - Country:US
Practice Address - Phone:808-735-9093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD3515174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04569301Medicaid
HID43629Medicare UPIN
HI04569301Medicaid