Provider Demographics
NPI:1023012994
Name:WILSON, JEFFREY LEE (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
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 1:7600 FRANCE AVE S STE 5100
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5924
Mailing Address - Country:US
Mailing Address - Phone:952-893-1959
Mailing Address - Fax:952-893-1954
Practice Address - Street 1:7600 FRANCE AVE S STE 5100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-893-1959
Practice Address - Fax:952-893-1954
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42120207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1547628OtherAMERICA'S PPO
MN351029800Medicaid
MN660003750OtherRR MEDICARE
MN960081023350OtherPREFERRED ONE
MN150037C477OtherUCARE
MN411774839A010OtherCHAMPUS
MN56G59WIOtherBLUE CROSS BLUE SHIELD
MNHP29582OtherHEALTHPARTNERS
MN3200087OtherMEDICA