Provider Demographics
NPI:1720275506
Name:WILSON, JOHN VERNON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VERNON
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 1:5007 HATTERAS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-6432
Mailing Address - Country:US
Mailing Address - Phone:636-734-7617
Mailing Address - Fax:
Practice Address - Street 1:1501 UNION AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9469
Practice Address - Country:US
Practice Address - Phone:660-263-9095
Practice Address - Fax:660-263-0054
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010027808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics