Provider Demographics
NPI:1205871563
Name:TIMOTHY J. WILSON, D.O, PLLC
Entity type:Organization
Organization Name:TIMOTHY J. WILSON, D.O, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-242-1032
Mailing Address - Street 1:1132 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5704
Mailing Address - Country:US
Mailing Address - Phone:304-242-1032
Mailing Address - Fax:
Practice Address - Street 1:1132 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5704
Practice Address - Country:US
Practice Address - Phone:304-242-1032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2665272Medicaid
WV3810005848Medicaid
WV3810005848Medicaid