Provider Demographics
NPI:1053346452
Name:WILSON, LUKE A (MD)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 W 110TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2382
Mailing Address - Country:US
Mailing Address - Phone:913-599-6777
Mailing Address - Fax:913-599-3955
Practice Address - Street 1:1000 CARONDELET DR
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4673
Practice Address - Country:US
Practice Address - Phone:913-599-6777
Practice Address - Fax:913-599-3955
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050140172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS34908019OtherBLUE CROSS BLUE SHIELD
MO207357609Medicaid
KSJ04D877CMedicare PIN
KS34908019OtherBLUE CROSS BLUE SHIELD
MOJ04D877BMedicare ID - Type Unspecified