Provider Demographics
NPI:1013193093
Name:WILSON, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641
Mailing Address - Country:US
Mailing Address - Phone:802-223-4738
Mailing Address - Fax:802-223-6067
Practice Address - Street 1:156 MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2702
Practice Address - Country:US
Practice Address - Phone:802-223-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0013743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008033190Medicaid
CT008033190Medicaid