Healthcare Provider Details

I. General information

NPI: 1538162151
Provider Name (Legal Business Name): JOHN FRASER WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8679 CONNECTICUT ST STE A
MERRILLVILLE IN
46410-6383
US

IV. Provider business mailing address

8679 CONNECTICUT ST STE A
MERRILLVILLE IN
46410-6383
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-9022
  • Fax: 219-769-1918
Mailing address:
  • Phone: 219-769-9022
  • Fax: 219-769-1918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01049994A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: