Provider Demographics
NPI:1922444132
Name:WILSON, JEFFERIE MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERIE
Middle Name:MICHAEL
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 1:559 VINCENT ST
Mailing Address - Street 2:ATTN: 21 HCOS/SGOC - PEDS
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1540
Mailing Address - Country:US
Mailing Address - Phone:719-556-1197
Mailing Address - Fax:877-813-1756
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:ATTN: 21 HCOS/SGOC - PEDS
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1540
Practice Address - Country:US
Practice Address - Phone:719-556-1197
Practice Address - Fax:877-813-1756
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK29958208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program