Healthcare Provider Details

I. General information

NPI: 1043218662
Provider Name (Legal Business Name): JAMES R WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

PO BOX 150505
ALTAMONTE SPRINGS FL
32715-0505
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-1944
  • Fax: 407-303-1746
Mailing address:
  • Phone: 407-767-0433
  • Fax: 407-767-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME76977
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35441
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME76977
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: