Provider Demographics
NPI:1437104114
Name:WILSON, GEORGE DEAN JR (MD)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:DEAN
Last Name:WILSON
Suffix:JR
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 1:3908 MARABLE LANE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601
Mailing Address - Country:US
Mailing Address - Phone:423-283-4677
Mailing Address - Fax:423-283-9722
Practice Address - Street 1:105 WOODLAWN DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37602-5978
Practice Address - Country:US
Practice Address - Phone:423-928-6174
Practice Address - Fax:423-926-2258
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0111662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64796980Medicaid
TN130014480OtherRR MEDICARE
NC7906816Medicaid
1292658OtherUMWA
602005579OtherPHP CARITEN
TN0118991OtherBCBS
0140000775OtherCIGNA
VA6196853Medicaid
A55508OtherJOHN DEERE
TN164888600OtherOWCP GROUP ID
TN3168835Medicaid
B03305Medicare UPIN
B03309Medicare UPIN
TN3168835Medicaid