Provider Demographics
NPI:1548243678
Name:WILSON, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:675 W NORTH AVE STE 608
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1627
Mailing Address - Country:US
Mailing Address - Phone:708-681-7879
Mailing Address - Fax:708-681-7886
Practice Address - Street 1:1S443 SUMMIT AVE
Practice Address - Street 2:SUITE# 203
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-3989
Practice Address - Country:US
Practice Address - Phone:630-678-9240
Practice Address - Fax:630-678-9243
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360884302084N0400X, 2084N0600X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1635130OtherBCBS
IL036088430Medicaid
ILF32730Medicare UPIN
IL211496Medicare ID - Type Unspecified