Provider Demographics
NPI:1568408698
Name:WILSON, YVONNE J (MD)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:J
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 1:1120 E WAR MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-7757
Mailing Address - Country:US
Mailing Address - Phone:309-685-0100
Mailing Address - Fax:309-685-0172
Practice Address - Street 1:2535 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-1863
Practice Address - Country:US
Practice Address - Phone:309-694-6464
Practice Address - Fax:309-694-6465
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036114805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114805Medicaid
ILK27662Medicare ID - Type Unspecified
IL036114805Medicaid