Provider Demographics
NPI:1619289881
Name:WILSON, JOHANNA S (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:S
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 1:2267 VILLAGE MALL DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-1369
Mailing Address - Country:US
Mailing Address - Phone:419-951-2020
Mailing Address - Fax:
Practice Address - Street 1:2267 VILLAGE MALL DR
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1369
Practice Address - Country:US
Practice Address - Phone:419-951-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-05
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1229522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry