Basic Information
Provider Information
NPI: 1003803057
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILSON
FirstName: JOHN
MiddleName: EVERETT
NamePrefix:  
NameSuffix:  
Credential: D..O
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208100000XH0045242MDY Allopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation 

ID Information
IDTypeStateIssuerDescription
H004524201MDSTATE LICENSEOTHER
OW25NE01MDBCBSOTHER


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