Healthcare Provider Details

I. General information

NPI: 1003287079
Provider Name (Legal Business Name): JEFFREY P WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE STE 300
FENTON MO
63026-2387
US

IV. Provider business mailing address

345 W STEAMBOAT DR STE 601
NORTH SIOUX CITY SD
57049-5287
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-5065
  • Fax:
Mailing address:
  • Phone:
  • Fax: 605-217-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number147427
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036165783
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036165783
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2025010674
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036165783
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number10415
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: