Provider Demographics
NPI:1417065715
Name:WILSON, JEFFREY WHITESIDE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WHITESIDE
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 1:10229 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214
Mailing Address - Country:US
Mailing Address - Phone:414-453-6330
Mailing Address - Fax:414-453-6523
Practice Address - Street 1:10229 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214
Practice Address - Country:US
Practice Address - Phone:414-453-6330
Practice Address - Fax:414-453-6523
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
11713OtherAMER BOARD OF PSYCH NEURO
WI31772200Medicaid
WI73863Medicare ID - Type Unspecified
WI31772200Medicaid