Provider Demographics
NPI:1235138801
Name:WILSON, JOHN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
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 1:312 E ALTA VISTA
Mailing Address - Street 2:ORHC CLINICS
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501
Mailing Address - Country:US
Mailing Address - Phone:641-684-3000
Mailing Address - Fax:641-684-2469
Practice Address - Street 1:931 PENNSYLVANIA AVE
Practice Address - Street 2:OTTUMWA PEDIATRICS
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501
Practice Address - Country:US
Practice Address - Phone:641-684-3000
Practice Address - Fax:641-684-2469
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36914208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA28375OtherBCBS OF IA
DE0000576001Medicaid
IAJA0171OtherJOHN DEERE HEALTH
IA0746719Medicaid
IA0746719Medicaid
DE0000576001Medicaid