Provider Demographics
NPI:1194019729
Name:WILSON, JOHN ALLEN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALLEN
Last Name:WILSON
Suffix:JR
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 1:7327 ROGERS POINT RD NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MN
Mailing Address - Zip Code:56484-2523
Mailing Address - Country:US
Mailing Address - Phone:218-836-2310
Mailing Address - Fax:
Practice Address - Street 1:7327 ROGERS POINT RD NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MN
Practice Address - Zip Code:56484-2523
Practice Address - Country:US
Practice Address - Phone:218-836-2310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15004207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD$$$$$$$$$-AMedicare PIN