Provider Demographics
NPI:1114910080
Name:WILSON, JOHNNY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:136 EL CHICO TRL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-8863
Mailing Address - Country:US
Mailing Address - Phone:817-441-1441
Mailing Address - Fax:817-441-1443
Practice Address - Street 1:136 EL CHICO TRL
Practice Address - Street 2:SUITE 103
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087-8863
Practice Address - Country:US
Practice Address - Phone:817-441-1441
Practice Address - Fax:817-441-1443
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL4177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1164502OtherAFFILIATED HEALTHCARE
TXL4177OtherUNICARE
TX0072KCOtherBLUE CROSS BLUE SHIELD
TX0082174OtherBLUE LINK
TX1354278OtherFOCUS
TX7111148OtherAETNA/TRS COORDINATED CAR
TX158350203Medicaid
TX158350201Medicaid
TXWILJC67146OtherCHIP HEALTHPLAN
TXWILJC67146OtherCHIP HEALTHPLAN
TX158350203Medicaid
TX00769HMedicare PIN