Provider Demographics
NPI:1184713463
Name:WILSON, JOHN WELLS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WELLS
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 1:85100 CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-9838
Mailing Address - Country:US
Mailing Address - Phone:415-279-4670
Mailing Address - Fax:
Practice Address - Street 1:1590 EAST 13TH AVE.
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1217
Practice Address - Country:US
Practice Address - Phone:541-346-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR190110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F59222Medicare UPIN
ZZZ22965ZMedicare ID - Type Unspecified