Provider Demographics
NPI:1477714400
Name:WILSON, TERRENCE JAMES (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 FRESNEL LN
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-7514
Mailing Address - Country:US
Mailing Address - Phone:252-567-2456
Mailing Address - Fax:
Practice Address - Street 1:126 FRESNEL LN
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-7514
Practice Address - Country:US
Practice Address - Phone:252-567-2456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH78512081P2900X
GA604852081P2900X
LAMD.2017722081P2900X
CAG888062081P2900X
CT450412081P2900X
FLME1473912081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B05349Medicare UPIN