MEDICARE: DAVID E WILSON MD LLC

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	207Q00000X	Family Medicine Physician	R4908	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110042554	OTHER	MO	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	04489010	OTHER	MO	BLUE CROSS OF KANSAS CITY INDIVIDUAL#

General Provider Information

NPI Number	:	1619421674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID E WILSON MD LLC

Provider Business Mailing Address
First Line	:	190 NE 91ST ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-3329
Country	:	US
Telephone Number	:	816-804-5223
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 NE 91ST ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-3329
Country	:	US
Telephone Number	:	816-804-5223
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. DAVID E WILSON
Credential	:	M.D.
Telephone Number	:	816-804-5223

Provider Enumeration Date	:	08/08/2016
Last Update Date	:	05/03/2024

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