Provider Demographics
NPI:1255317186
Name:WILSON, JOHN ELWOOD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ELWOOD
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 1:1215 PLEASANT ST STE 400
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1418
Mailing Address - Country:US
Mailing Address - Phone:515-241-5722
Mailing Address - Fax:
Practice Address - Street 1:1215 PLEASANT ST
Practice Address - Street 2:SUITE 400
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1416
Practice Address - Country:US
Practice Address - Phone:515-241-5722
Practice Address - Fax:515-241-4403
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20335207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4268OtherMIDLANDS PROVIDER #
IA15095OtherBLUE SHIELD PROVIDER #
IAIA0114OtherJOHN DEERE PROVIDER #
IA0150953Medicaid
IA20335OtherTRICARE PROVIDER #
IA15095OtherBLUE SHIELD PROVIDER #
IA20335OtherTRICARE PROVIDER #