Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 150495 | OR |
N | 207QA0505X | Family Doctor - Adult Medicine | MD37095 | TN |
NPI | 1104071224 |
---|---|
Provider Name | Dr. John David Wilson |
First Address | Grants Pass, OR 97527-5681 |
Second Address | Grants Pass, OR 97527-5681 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/11/2008 |
Last Update Date | 06/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
500622415 | (05) | OR |