Provider Demographics
NPI:1639142151
Name:WILSON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-2273
Mailing Address - Fax:417-347-2277
Practice Address - Street 1:1130 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4034
Practice Address - Country:US
Practice Address - Phone:417-347-2273
Practice Address - Fax:417-347-2277
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036901A207Q00000X
MO2013021433207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100336610Medicaid
INE11153Medicare UPIN
IN911660HMedicare ID - Type Unspecified
IN370640HMedicare ID - Type Unspecified
IN100336610Medicaid