Provider Demographics
NPI:1356331821
Name:WILSON, RICHARD BOULWARE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BOULWARE
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 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:2407 RUTH HENTZ AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2259
Practice Address - Country:US
Practice Address - Phone:850-522-5022
Practice Address - Fax:850-387-0807
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43810OtherBLUE SHIELD PROV #
FL43810ZMedicare ID - Type UnspecifiedINDIVIDUAL PROV NUMBER
FL00874Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
FL43810OtherBLUE SHIELD PROV #