Provider Demographics
NPI:1407816218
Name:WILSON, JON DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DANIEL
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 1:10810 EXECUTIVE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4386
Mailing Address - Country:US
Mailing Address - Phone:501-604-2695
Mailing Address - Fax:501-604-2699
Practice Address - Street 1:10810 EXECUTIVE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4386
Practice Address - Country:US
Practice Address - Phone:501-604-2695
Practice Address - Fax:501-604-2699
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076903207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4244846Medicaid
MI220F362370OtherBCBSM
MI4244846Medicaid
MIH23931Medicare UPIN