Provider Demographics
NPI:1215197090
Name:JOHN W WILSON D O P A
Entity Type:Organization
Organization Name:JOHN W WILSON D O P A
Other - Org Name:JOHN W WILSON DO PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-889-1194
Mailing Address - Street 1:2011 N COLLINS BLVD
Mailing Address - Street 2:609
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2645
Mailing Address - Country:US
Mailing Address - Phone:972-889-1194
Mailing Address - Fax:972-889-1425
Practice Address - Street 1:2011 N COLLINS BLVD
Practice Address - Street 2:609
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2645
Practice Address - Country:US
Practice Address - Phone:972-889-1194
Practice Address - Fax:972-889-1425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN W WILSON D O P A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-14
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6952207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195978501Medicaid
TX195978501Medicaid