Provider Demographics
NPI:1922108745
Name:WILSON, JEFFREY LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1810 ELDRON BLVD., SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909
Practice Address - Country:US
Practice Address - Phone:321-434-3430
Practice Address - Fax:321-434-3432
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14088207Q00000X, 207Q00000X
NC99-00390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIS227ZOtherFL MEDICARE
FL019335700Medicaid