Healthcare Provider Details

I. General information

NPI: 1558398628
Provider Name (Legal Business Name): STEPHEN D. WILSON M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

1635 DIVISADERO STREET SUITE 625, BOX 1821
SAN FRANCISCO CA
94143-0001
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-5943
  • Fax: 415-476-4009
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG76355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: