Individual
DR. JOHN M. WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1235 E CHEROKEE ST, SPRINGFIELD, MO 65804-2203
(417) 820-9729
(417) 820-6471
Mailing address
PO BOX 505164, SAINT LOUIS, MO 63150-5164
(417) 829-4620
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
R3L99
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
128675001
—
AR
01
—
173098
MO BLUE SHIELD
MO
05
—
202845509
—
MO
01
—
81802
ARK BLUE SHIELD
AR
Enumeration date
02/02/2007
Last updated
03/12/2014
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