Provider Demographics
NPI:1588041099
Name:WILSON, SARAH JO (MD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:JO
Other - Last Name:WETHERINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1118 W WRIGHTWOOD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1315
Mailing Address - Country:US
Mailing Address - Phone:404-513-6372
Mailing Address - Fax:
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1600
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2997
Practice Address - Country:US
Practice Address - Phone:404-513-6372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.148813207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery