Provider Demographics
NPI:1952694549
Name:WILSON, BENJAMIN J (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
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 1:1932 E STAR LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5559
Mailing Address - Country:US
Mailing Address - Phone:208-547-5697
Mailing Address - Fax:208-649-2658
Practice Address - Street 1:1908 BOOTHE CIR
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-6774
Practice Address - Country:US
Practice Address - Phone:844-665-4827
Practice Address - Fax:855-437-3395
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8438943-1205207Q00000X
WAMD60771670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine