Provider Demographics
NPI:1922119502
Name:WILSON, JOSEPH RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RICHARD
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 1:610 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4704
Mailing Address - Country:US
Mailing Address - Phone:507-451-8807
Mailing Address - Fax:
Practice Address - Street 1:610 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4704
Practice Address - Country:US
Practice Address - Phone:507-451-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN319722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN269000247OtherMEDICARE PTAN
MNHP18408OtherHEALTH PARTNERS
MN105813OtherUCARE
MN230203900Medicaid
MN69221WIOtherBLUECROSSBLUESHIELD
MN15-12382OtherUNITED BEHAVIORAL HEALTH
MN269000247OtherMEDICARE PTAN