Healthcare Provider Details

I. General information

NPI: 1063639391
Provider Name (Legal Business Name): JOHN M WILSON MD P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 SEAGULL ST NE B-109
ALBUQUERQUE NM
87109-2500
US

IV. Provider business mailing address

6100 SEAGULL ST NE B-109
ALBUQUERQUE NM
87109-2500
US

V. Phone/Fax

Practice location:
  • Phone: 505-878-9000
  • Fax: 505-878-8902
Mailing address:
  • Phone: 505-878-9000
  • Fax: 505-878-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number96-161
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number96-161
License Number StateNM

VIII. Authorized Official

Name: DR. JOHN M WILSON
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 505-878-9000