Provider Demographics
NPI:1982691598
Name:WILSON, RICHARD W (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
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 1:999 N CURTIS RD
Mailing Address - Street 2:STE 506
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1336
Mailing Address - Country:US
Mailing Address - Phone:208-367-2800
Mailing Address - Fax:208-367-2876
Practice Address - Street 1:999 N CURTIS RD
Practice Address - Street 2:STE 506
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1336
Practice Address - Country:US
Practice Address - Phone:208-367-2800
Practice Address - Fax:208-367-2876
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM37752084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003992400Medicaid
C47818Medicare UPIN
ID003992400Medicaid