Provider Demographics
NPI:1710174628
Name:WILSON, JOHN TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TRAVIS
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 1:320 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4756
Mailing Address - Country:US
Mailing Address - Phone:412-359-6550
Mailing Address - Fax:412-359-6494
Practice Address - Street 1:320 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-359-6550
Practice Address - Fax:412-359-6494
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD433645207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027273630001Medicaid
WV3810023662Medicaid
PA242998QJDMedicare PIN
OH0067461Medicare UPIN
PAP01193951Medicare PIN