Provider Demographics
NPI:1972598316
Name:WILSON, WILLIAM LE ROY (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LE ROY
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 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG. 3, SUITE 540
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-460-2700
Mailing Address - Fax:619-460-2702
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG. 3, SUITE 540
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-460-2700
Practice Address - Fax:619-460-2702
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2021-02-26
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
CAG44872208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G448720Medicaid
CA00G448720Medicaid
CAA49788Medicare UPIN