Provider Demographics
NPI:1972676153
Name:WILSON, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
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 1:1200 HILYARD ST
Mailing Address - Street 2:SUITE S-560
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-8122
Mailing Address - Country:US
Mailing Address - Phone:541-343-6028
Mailing Address - Fax:541-485-7702
Practice Address - Street 1:1200 HILYARD ST
Practice Address - Street 2:SUITE S-560
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8122
Practice Address - Country:US
Practice Address - Phone:541-343-6028
Practice Address - Fax:541-485-7702
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10554207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR242248Medicaid
OR242248Medicaid
ORUPINMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER