Provider Demographics
NPI:1760598239
Name:WILSON, IAN J (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:J
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 1:625 AFRICA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9808
Mailing Address - Country:US
Mailing Address - Phone:614-891-8080
Mailing Address - Fax:614-891-7078
Practice Address - Street 1:625 AFRICA RD STE 200
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082
Practice Address - Country:US
Practice Address - Phone:614-891-8080
Practice Address - Fax:614-891-7078
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045266207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0467632Medicaid
A84138Medicare UPIN
OH0467632Medicaid