1902855455 NPI number — JOHN J WILSON MD

Table of content: JOHN J WILSON MD (NPI 1902855455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902855455 NPI number — JOHN J WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JOHN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902855455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 BOWMAN DRIVE
Provider Second Line Business Mailing Address:
STE 190
Provider Business Mailing Address City Name:
VOORHEES TOWNSHIP
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08043-9634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-247-7370
Provider Business Mailing Address Fax Number:
856-247-7331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 BOWMAN DRIVE
Provider Second Line Business Practice Location Address:
STE 190
Provider Business Practice Location Address City Name:
VOORHEES TOWNSHIP
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-9634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-261-7074
Provider Business Practice Location Address Fax Number:
856-247-7331
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  MD422915 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 25MA08052600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0128244 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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