Provider Demographics
NPI:1114920444
Name:WILCOX, JOHN RICHARDSON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARDSON
Last Name:WILCOX
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5316
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-5316
Mailing Address - Country:US
Mailing Address - Phone:903-663-4800
Mailing Address - Fax:903-663-0378
Practice Address - Street 1:4777 US HIGHWAY 259
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7668
Practice Address - Country:US
Practice Address - Phone:903-663-4800
Practice Address - Fax:903-663-0378
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF08242085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DB361OtherBCBS TX
TX134263610Medicaid
TX134263613Medicaid
TXP00995222OtherRR MEDICARE
TXP00995222OtherRR MEDICARE
TXA91358Medicare UPIN
TX8B5707Medicare PIN