Provider Demographics
NPI:1700952744
Name:WILSON, JASON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DAVID
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 1:4410 MEDICAL DR STE 320
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3749
Mailing Address - Country:US
Mailing Address - Phone:210-874-3270
Mailing Address - Fax:
Practice Address - Street 1:4410 MEDICAL DR STE 320
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3749
Practice Address - Country:US
Practice Address - Phone:210-874-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA205122207T00000X
TXS9627207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2183559Medicaid
AL51115470OtherBLUE CROSS
TX1M8463OtherMEDICARE
IN200974460Medicaid
AL128732Medicaid
LA4Q875Medicare PIN