Provider Demographics
NPI:1851378145
Name:WILSON, JACK J (MD)
Entity Type:Individual
Prefix:
First Name:JACK
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:5801 BREMO RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1907
Practice Address - Country:US
Practice Address - Phone:804-281-8100
Practice Address - Fax:804-285-7419
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58840207V00000X
FL58840207ZH0000X, 207ZP0102X
LA304638207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052455700Medicaid
FL052455700Medicaid
FL18977YMedicare PIN