Provider Demographics
NPI:1083644025
Name:JACK J WILSON MD PA
Entity Type:Organization
Organization Name:JACK J WILSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-628-0853
Mailing Address - Street 1:2025 SUMMERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1453
Mailing Address - Country:US
Mailing Address - Phone:407-628-0853
Mailing Address - Fax:407-628-0853
Practice Address - Street 1:2025 SUMMERLAND AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1453
Practice Address - Country:US
Practice Address - Phone:407-628-0853
Practice Address - Fax:407-628-0853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0058840207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1104Medicare PIN