Provider Demographics
NPI:1679673560
Name:WILSON, JOHN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6174
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:ER ADMINISTRATION
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-6372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14469207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863OtherBCBS
SC930129083OtherMEDICARE RAILROAD
SC144695Medicaid
SC576007863OtherUHC
SC576007863OtherAETNA
SC20004420OtherSELECT HEATLTH
SC576007863OtherBLUE CHOICE