Basic Information
| Provider Information | |||||||||
| NPI: | 1851316517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LLOYD | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | PAUL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 53 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416877134 | ||||||||
| FaxNumber: | 5416877135 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 HILYARD ST STE 410 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416818586 | ||||||||
| FaxNumber: | 5416818587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD11715 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8004138-01 | 01 | OR | BCBS | OTHER | 8296717 | 05 | WA | MEDICAID | MD5436R | 05 | AK | MEDICAID | 260828 | 05 | OR | MEDICAID | 8005089-09 | 01 | OR | BCBS | OTHER | MD5435R | 05 | AK | MEDICAID |