Provider Demographics
NPI:1275662439
Name:DR JOHN T WILSON PC
Entity Type:Organization
Organization Name:DR JOHN T WILSON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-262-0542
Mailing Address - Street 1:1515 TILLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-6933
Mailing Address - Country:US
Mailing Address - Phone:912-262-0542
Mailing Address - Fax:912-262-6538
Practice Address - Street 1:1515 TILLMAN AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-6933
Practice Address - Country:US
Practice Address - Phone:912-262-0542
Practice Address - Fax:912-262-6538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010583122300000X
GADNO12937122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00353768BMedicaid
GA774804023BMedicaid
GA9180215OtherDORAL
GA000353768CMedicaid
GA774804023AMedicaid
GA9180264OtherDORAL