Provider Demographics
NPI:1689697542
Name:WILSON, DONNA JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA JEAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 N UNIVERSITY AVE
Mailing Address - Street 2:C/O CARENCRO SCHOOL BASED HEALTH CENTER
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-3905
Mailing Address - Country:US
Mailing Address - Phone:337-521-7499
Mailing Address - Fax:337-521-7498
Practice Address - Street 1:4301 N UNIVERSITY AVE
Practice Address - Street 2:C/O CARENCRO SCHOOL BASED HEALTH CENTER
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-3905
Practice Address - Country:US
Practice Address - Phone:337-521-7499
Practice Address - Fax:337-521-7498
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07679R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1378542Medicaid
LA54873Medicare PIN
LA1378542Medicaid
LA54873F670Medicare PIN