Provider Demographics
NPI:1003803057
Name:WILSON, JOHN EVERETT (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EVERETT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 C NORTH AVE
Mailing Address - Street 2:SUITE 425
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-2307
Mailing Address - Country:US
Mailing Address - Phone:410-838-8991
Mailing Address - Fax:410-838-0727
Practice Address - Street 1:4 C NORTH AVE
Practice Address - Street 2:SUITE 425
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-2307
Practice Address - Country:US
Practice Address - Phone:410-838-8991
Practice Address - Fax:410-838-0727
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0045242208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDOW25NEOtherBCBS
MDH0045242OtherSTATE LICENSE
548M853FMedicare ID - Type Unspecified
MDOW25NEOtherBCBS