Provider Demographics
NPI:1457343063
Name:WILSON, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
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 1:2900 12TH AVE N
Mailing Address - Street 2:SUITE 140W
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7506
Mailing Address - Country:US
Mailing Address - Phone:406-238-6540
Mailing Address - Fax:406-238-6599
Practice Address - Street 1:2900 12TH AVE N
Practice Address - Street 2:SUITE 140W
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7506
Practice Address - Country:US
Practice Address - Phone:406-238-6540
Practice Address - Fax:406-238-6599
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8411207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000091778OtherBLUECROSS BLUESHIELD
MT108160Medicaid
WY114452900Medicaid
MT200033018OtherRR MEDICARE
MT000091778OtherBLUECROSS BLUESHIELD
MT10001619Medicare PIN