MEDICARE: GLEN P WILSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	2000-314	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	600521002	OTHER	NM	MEDICARE IDTF
3	700521102	OTHER	NM	MEDICARE GROUP
4	2258272	OTHER	NM	MEDICARE GROUP
8	800521126	OTHER	NM	MEDICARE IDTF

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285638999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN P WILSON M.D.

Provider Business Mailing Address
First Line	:	800 BRADBURY DR SE STE 116
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-4310
Country	:	US
Telephone Number	:	505-272-1476
Fax Number	:

Provider Business Practice Location Address
First Line	:	4901 LANG AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4495
Country	:	US
Telephone Number	:	505-842-8171
Fax Number	:	505-857-3877

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	10/30/2024

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Directions to “ GLEN P WILSON M.D.” Practice Location

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