Healthcare Provider Details

I. General information

NPI: 1679673560
Provider Name (Legal Business Name): JOHN DAVID WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD ER ADMINISTRATION
GREENVILLE SC
29605
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-6372
  • Fax:
Mailing address:
  • Phone: 864-797-6174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number14469
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: