Provider Demographics
NPI:1225002561
Name:WILSON, JAMES DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVID
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 1:350 HOSPITAL WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2872
Mailing Address - Country:US
Mailing Address - Phone:606-451-2662
Mailing Address - Fax:606-451-2641
Practice Address - Street 1:350 HOSPITAL WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2872
Practice Address - Country:US
Practice Address - Phone:606-451-2662
Practice Address - Fax:606-451-2641
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1183698OtherCHA
KY64289226Medicaid
5125851OtherCCN
C92457OtherCUMBERLAND HEALTHCARE
000000054066OtherANTHEM
5012148OtherAETNA
1183698OtherCHA
5125851OtherCCN
000000054066OtherANTHEM