Individual
JACK J WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5801 BREMO RD, RICHMOND, VA 23226-1907
(804) 281-8100
(804) 285-7419
Mailing address
1514 JEFFERSON HWY, NEW ORLEANS, LA 70121-2429
(504) 842-4000
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
ME58840
FL
207ZH0000X
Hematology (Pathology) Physician
58840
FL
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
304638
LA
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
58840
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
052455700
—
FL
Enumeration date
12/28/2005
Last updated
01/29/2019
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