Provider Demographics
NPI:1235169723
Name:WILSON, JOSEPH F (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:F
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 1:29 NW 1ST LN
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-8105
Mailing Address - Country:US
Mailing Address - Phone:417-681-5266
Mailing Address - Fax:417-681-5505
Practice Address - Street 1:29 NW 1ST LN
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-8105
Practice Address - Country:US
Practice Address - Phone:417-681-5266
Practice Address - Fax:417-681-5505
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N54207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1275730160OtherMEDICARE GROUP NUMBER
MO242951002Medicaid
010054184OtherRR MEDICARE
MO100616OtherANTHEM
MO242951002Medicaid
010054184OtherRR MEDICARE
MO019951433Medicare PIN