Provider Demographics
NPI:1689639270
Name:WILSON, JOHN STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEVEN
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 1:1034 GROVE ST
Mailing Address - Street 2:CBO
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-2923
Mailing Address - Fax:814-333-5640
Practice Address - Street 1:765 LIBERTY ST
Practice Address - Street 2:SUITE 105
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2566
Practice Address - Country:US
Practice Address - Phone:814-373-2310
Practice Address - Fax:814-373-2313
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD052384L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014676790001Medicaid
0764259OtherBS
764259F2JMedicare ID - Type Unspecified
PA0014676790001Medicaid