Provider Demographics
NPI:1962443226
Name:WILSON, JAMES MARION (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MARION
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1913 MILLBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-1485
Mailing Address - Country:US
Mailing Address - Phone:423-282-5612
Mailing Address - Fax:423-282-5612
Practice Address - Street 1:JAMES QUILLEN MEDICAL CENTER
Practice Address - Street 2:MOUTAIN HOME VA
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:423-979-3427
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000009412208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3172401Medicaid
TNB03531Medicare UPIN
TN3172402Medicare ID - Type Unspecified