Provider Demographics
NPI:1376606533
Name:JAMES R WILSON MD PA
Entity type:Organization
Organization Name:JAMES R WILSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-683-8120
Mailing Address - Street 1:3017 LANDOVER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608
Mailing Address - Country:US
Mailing Address - Phone:352-683-8120
Mailing Address - Fax:352-683-4588
Practice Address - Street 1:3017 LANDOVER BOULEVARD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-7260
Practice Address - Country:US
Practice Address - Phone:352-683-8120
Practice Address - Fax:352-683-4588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0014846207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29614Medicare ID - Type Unspecified
D62087Medicare UPIN