Provider Demographics
NPI:1205981115
Name:WILSON, JAMES MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MATTHEW
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:
Practice Address - Street 1:482 HAWTHORNE DR NE
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-2970
Practice Address - Country:US
Practice Address - Phone:276-437-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250849207Q00000X
SC28201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY71000185520Medicaid
VAP01081218OtherRR MEDICARE
VA1205981115Medicaid
VAP01081218OtherRR MEDICARE
VAVV5012AMedicare PIN