Provider Demographics
NPI:1467972497
Name:WILSON, JOSEPH GEORGE
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:GEORGE
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 S ARDMORE AVE
Mailing Address - Street 2:SUITE PO BOX 5815
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-5309
Mailing Address - Country:US
Mailing Address - Phone:219-214-2047
Mailing Address - Fax:
Practice Address - Street 1:10176 W 400 N STE D
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9009
Practice Address - Country:US
Practice Address - Phone:219-214-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16.005870213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery