Provider Demographics
NPI:1679689897
Name:WILSON, JOHN KEDDY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEDDY
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3300 WOODBURN RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1202
Mailing Address - Country:US
Mailing Address - Phone:703-205-9452
Mailing Address - Fax:703-208-0714
Practice Address - Street 1:3300 WOODBURN RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1202
Practice Address - Country:US
Practice Address - Phone:703-205-9452
Practice Address - Fax:703-208-0714
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012329302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H79537Medicare UPIN
010899M25Medicare ID - Type Unspecified