Provider Demographics
NPI:1952538605
Name:WILSON, PRESTON JON (DO)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:JON
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 198560
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8560
Mailing Address - Country:US
Mailing Address - Phone:801-576-8855
Mailing Address - Fax:801-576-9800
Practice Address - Street 1:8846 S REDWOOD RD STE E121
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9366
Practice Address - Country:US
Practice Address - Phone:801-569-1999
Practice Address - Fax:801-569-2001
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125-056771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine