Provider Demographics
NPI:1225020878
Name:WILSON, BRADLEY C (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1821
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43702-1821
Mailing Address - Country:US
Mailing Address - Phone:740-455-3304
Mailing Address - Fax:740-455-3686
Practice Address - Street 1:7756 STATE ROUTE 37 E
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-9512
Practice Address - Country:US
Practice Address - Phone:740-342-3540
Practice Address - Fax:740-342-3879
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2427136Medicaid
A17170Medicare UPIN
OH0737224Medicare PIN
OH2427136Medicaid