Healthcare Provider Details

I. General information

NPI: 1548243678
Provider Name (Legal Business Name): JOHN R WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 W NORTH AVE STE 304
MELROSE PARK IL
60160-1426
US

IV. Provider business mailing address

1440 W NORTH AVE STE 304
MELROSE PARK IL
60160-1426
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-7879
  • Fax: 708-681-7886
Mailing address:
  • Phone: 708-681-7879
  • Fax: 708-681-7886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036088430
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number036088430
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number036088430
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: