Provider Demographics
NPI:1508126921
Name:WILSON, JOI VENICE (MD)
Entity Type:Individual
Prefix:
First Name:JOI
Middle Name:VENICE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 HALE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6373
Mailing Address - Country:US
Mailing Address - Phone:901-396-0390
Mailing Address - Fax:
Practice Address - Street 1:1129 HALE RD
Practice Address - Street 2:MADISON AVENUE SUITE 1031
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6373
Practice Address - Country:US
Practice Address - Phone:901-396-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN52880208000000X
MS23902208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program