Provider Demographics
NPI:1326090739
Name:WILSON, JAMES T III (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:WILSON
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:8039 VISTA FOREST DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5707
Mailing Address - Country:US
Mailing Address - Phone:540-985-8454
Mailing Address - Fax:540-985-8345
Practice Address - Street 1:102 HIGHLAND AVE SE
Practice Address - Street 2:SUITE 104
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2256
Practice Address - Country:US
Practice Address - Phone:540-985-8454
Practice Address - Fax:540-985-8345
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-11-19
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Provider Licenses
StateLicense IDTaxonomies
VA01010346442084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006199712Medicaid
VAB05006Medicare UPIN
VA130000109Medicare ID - Type Unspecified