Provider Demographics
NPI:1669457974
Name:WILSON, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 LIVE OAK ST
Practice Address - Street 2:EAST DALLAS HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6109
Practice Address - Country:US
Practice Address - Phone:214-266-1000
Practice Address - Fax:214-266-1128
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140177023Medicaid
TX140177025Medicaid
TX140177015Medicaid
TX140177013Medicaid
TX140177020Medicaid
TX140177022Medicaid
TX110186000OtherRAILROAD MEDICARE
TX140177016Medicaid
TX140177021Medicaid
TX140177024Medicaid
TX140177012Medicaid
TX87W582OtherBLUE CROSS BLUE SHIELD
TX140177019Medicaid
TX140177016Medicaid
TX140177023Medicaid