Individual
GARY L WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1000 BRECKENRIDGE ST, SUITE 404, OWENSBORO, KY 42303-0878
(270) 691-8050
(270) 691-8051
Mailing address
1000 BRECKENRIDGE ST, SUITE 404, OWENSBORO, KY 42303-0878
(270) 691-8050
(270) 691-8051
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
Primary
42171
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000588181
BCBS PIN#
KY
05
—
7100065360
—
KY
Enumeration date
09/29/2005
Last updated
05/02/2019
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