Provider Demographics
NPI:1962639237
Name:WILSON, JEFFREY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
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 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:419-462-3485
Mailing Address - Fax:419-462-4582
Practice Address - Street 1:715 RICHLAND MALL
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-3802
Practice Address - Country:US
Practice Address - Phone:419-468-0732
Practice Address - Fax:419-563-9862
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD450932208800000X
OH35.148953208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology