Provider Demographics
NPI:1144206962
Name:WILSON, JERRY PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:PAUL
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 1:6041 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-3448
Mailing Address - Country:US
Mailing Address - Phone:731-686-1505
Mailing Address - Fax:731-686-8174
Practice Address - Street 1:6041 TELECOM DR
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3448
Practice Address - Country:US
Practice Address - Phone:731-686-1505
Practice Address - Fax:731-686-8174
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD24812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3078043Medicaid
TN3078043Medicare ID - Type Unspecified
TN3078043Medicaid