Provider Demographics
NPI:1063639391
Name:JOHN M WILSON MD P C
Entity Type:Organization
Organization Name:JOHN M WILSON MD P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-878-9000
Mailing Address - Street 1:6100 SEAGULL ST NE
Mailing Address - Street 2:B-109
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2500
Mailing Address - Country:US
Mailing Address - Phone:505-878-9000
Mailing Address - Fax:505-878-8902
Practice Address - Street 1:6100 SEAGULL ST NE
Practice Address - Street 2:B-109
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2500
Practice Address - Country:US
Practice Address - Phone:505-878-9000
Practice Address - Fax:505-878-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96-161302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered302R00000XManaged Care OrganizationsHealth Maintenance Organization
Not Answered305R00000XManaged Care OrganizationsPreferred Provider Organization