Provider Demographics
NPI:1376727354
Name:WILSON, JONATHAN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LEE
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 1:4141 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6021
Mailing Address - Country:US
Mailing Address - Phone:605-341-2424
Mailing Address - Fax:605-341-4547
Practice Address - Street 1:4141 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6021
Practice Address - Country:US
Practice Address - Phone:605-341-2424
Practice Address - Fax:605-341-4547
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD8806207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery