Provider Demographics
NPI:1891750782
Name:WILSON, JOHN WINKLE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WINKLE
Last Name:WILSON
Suffix:JR
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:PO BOX 50760
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0013
Mailing Address - Country:US
Mailing Address - Phone:843-234-5139
Mailing Address - Fax:843-234-6822
Practice Address - Street 1:8002 MYRTLE TRACE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8945
Practice Address - Country:US
Practice Address - Phone:843-347-7227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC039746Medicaid
SCGP4505Medicaid
D75088Medicare UPIN
SCGP4505Medicaid
8906956Medicare PIN