Provider Demographics
NPI:1639461304
Name:WILSON, JARED MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:MICHAEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316TH MEDICAL GROUP
Mailing Address - Street 2:1060 W. PERIMETER RD
Mailing Address - City:JOINT BASE ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:134 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6523
Practice Address - Country:US
Practice Address - Phone:757-473-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12607207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology