Provider Demographics
NPI:1003287079
Name:WILSON, JEFFREY P (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
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 1:345 W STEAMBOAT DR STE 601
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5287
Mailing Address - Country:US
Mailing Address - Phone:605-217-5617
Mailing Address - Fax:605-217-5533
Practice Address - Street 1:1011 BOWLES AVE STE 300
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2387
Practice Address - Country:US
Practice Address - Phone:636-496-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036165783207R00000X, 207RC0000X, 207RI0011X, 207R00000X
IAMD-51990207RI0011X
SD10415207RI0011X
MO2025010674207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology