Provider Demographics
NPI:1144204652
Name:WILSON, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0404
Mailing Address - Fax:
Practice Address - Street 1:1750 NORTH HAMPTON ROAD
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115
Practice Address - Country:US
Practice Address - Phone:817-321-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ77302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041641403Medicaid
TX041641402Medicaid
TX8D3426Medicare PIN
E30480Medicare UPIN
TX300128894Medicare PIN
TX85788RMedicare PIN