Provider Demographics
NPI:1235148677
Name:WILSON, AMY JO (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1520
Mailing Address - Country:US
Mailing Address - Phone:214-820-9637
Mailing Address - Fax:214-820-9339
Practice Address - Street 1:909 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1520
Practice Address - Country:US
Practice Address - Phone:214-820-9637
Practice Address - Fax:214-820-9339
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4616208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047992503Medicaid
TX047992502Medicaid
TX047992501Medicaid
TX047992504Medicaid
TX8BR154OtherBCBS
TX047992501Medicaid
TX89X643Medicare PIN
TXG31731Medicare UPIN
TXTXB162705Medicare PIN
TXTXB162703Medicare PIN
TX8BR154OtherBCBS
TX81120JMedicare PIN
TX250013228Medicare PIN
TX8L3013Medicare PIN