Healthcare Provider Details

I. General information

NPI: 1235169723
Provider Name (Legal Business Name): JOSEPH F WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 NW 1ST LN
LAMAR MO
64759-8105
US

IV. Provider business mailing address

29 NW 1ST LN
LAMAR MO
64759-8105
US

V. Phone/Fax

Practice location:
  • Phone: 417-681-5266
  • Fax: 417-681-5505
Mailing address:
  • Phone: 417-681-5266
  • Fax: 417-681-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR8N54
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: