Basic Information
| Provider Information | |||||||||
| NPI: | 1265787303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREGORY B. WILSON, M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1329 LUSITANA ST | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085311116 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1329 LUSITANA ST | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085311116 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2012 | ||||||||
| LastUpdateDate: | 07/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8087359093 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD-03515 | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 04569301 | 05 | HI | MEDICAID | 00A0051910 | 01 | HI | HMSA | OTHER |