Basic Information
| Provider Information | |||||||||
| NPI: | 1003803057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EVERETT | ||||||||
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| Credential: | D..O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 C NORTH AVE | ||||||||
| Address2: | SUITE 425 | ||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210142307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108388991 | ||||||||
| FaxNumber: | 4108380727 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 C NORTH AVE | ||||||||
| Address2: | SUITE 425 | ||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210142307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108388991 | ||||||||
| FaxNumber: | 4108380727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | H0045242 | MD | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | OW25NE | 01 | MD | BCBS | OTHER | H0045242 | 01 | MD | STATE LICENSE | OTHER |