Healthcare Provider Details

I. General information

NPI: 1689676314
Provider Name (Legal Business Name): JEFFREY LEE WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 C PHYSICIANS BLVD
GLASGOW KY
42141-3462
US

IV. Provider business mailing address

102 PHYSICIANS BLVD C
GLASGOW KY
42141-1299
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-2433
  • Fax: 270-651-2949
Mailing address:
  • Phone: 270-651-2433
  • Fax: 270-651-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number34426
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: