Healthcare Provider Details

I. General information

NPI: 1720275506
Provider Name (Legal Business Name): JOHN VERNON WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W BROADWAY STE 4A
COLUMBIA MO
65203-3842
US

IV. Provider business mailing address

1801 CALEDON CT
COLUMBIA MO
65203-8458
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-0937
  • Fax:
Mailing address:
  • Phone: 636-734-7617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.MD.70061718
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2010027808
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: