Provider Demographics
NPI:1760878599
Name:WILSON, JOHN III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:WILSON
Suffix:III
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 1:212 W ROUTE 38 STE 105
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-4100
Mailing Address - Country:US
Mailing Address - Phone:856-600-4011
Mailing Address - Fax:
Practice Address - Street 1:212 W ROUTE 38 STE 105
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-4100
Practice Address - Country:US
Practice Address - Phone:856-600-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3094052084P0800X
NJ25MA104967002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry