Healthcare Provider Details

I. General information

NPI: 1275544033
Provider Name (Legal Business Name): BERNARD J WILSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S 70TH ST
LINCOLN NE
68510-2462
US

IV. Provider business mailing address

8055 O ST STE 300
LINCOLN NE
68510-2580
US

V. Phone/Fax

Practice location:
  • Phone: 402-219-7420
  • Fax: 402-219-7651
Mailing address:
  • Phone: 402-421-0896
  • Fax: 402-421-0945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number19185
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: