Provider Demographics
NPI:1366861841
Name:WILSON, WILLIAM CASSIDY IV (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:CASSIDY
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8131
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7200
Mailing Address - Fax:314-747-4189
Practice Address - Street 1:2200 E PARRISH AVE BLDG D
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1458
Practice Address - Country:US
Practice Address - Phone:270-926-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190095342085B0100X, 2085R0202X
KY531422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200067605Medicaid
ILENROLLEDMedicaid