Provider Demographics
NPI:1619292240
Name:WILSON, JOHN CAMPBELL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CAMPBELL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N INTERSTATE AVE
Mailing Address - Street 2:EAST INTERSTATE MEDICAL OFFICE - MENTAL HEALTH
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1196
Mailing Address - Country:US
Mailing Address - Phone:503-249-3434
Mailing Address - Fax:
Practice Address - Street 1:3550 N INTERSTATE AVE
Practice Address - Street 2:EAST INTERSTATE MEDICAL OFFICE - MENTAL HEALTH
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-249-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1580282084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry