Provider Demographics
NPI:1114227139
Name:WILSON, JOHN MARSHALL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARSHALL
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 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-361-6617
Mailing Address - Fax:502-361-6637
Practice Address - Street 1:1850 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-361-6617
Practice Address - Fax:502-361-6637
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP926207L00000X
KY47643207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100323720Medicaid
KYK153505OtherMEDICARE PIN