Provider Demographics
NPI:1902810914
Name:WILSON, STEPHEN CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-2328
Mailing Address - Country:US
Mailing Address - Phone:760-806-5660
Mailing Address - Fax:760-631-3435
Practice Address - Street 1:130 CEDAR RD # 350
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5102
Practice Address - Country:US
Practice Address - Phone:760-806-5660
Practice Address - Fax:760-631-3435
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27579208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G275790Medicaid
CA00G275790Medicaid
CAA43409Medicare UPIN