Provider Demographics
NPI:1952308066
Name:WILSON, GEORGE SCOTT (DO)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:SCOTT
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 1:356 E LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-1443
Mailing Address - Country:US
Mailing Address - Phone:330-420-0200
Mailing Address - Fax:330-420-0210
Practice Address - Street 1:356 E LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-1443
Practice Address - Country:US
Practice Address - Phone:330-420-0200
Practice Address - Fax:330-420-0210
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH34006974W207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2154056Medicaid
OH2154056Medicaid
OHSP04352Medicare PIN