Healthcare Provider Details

I. General information

NPI: 1679689897
Provider Name (Legal Business Name): JOHN KEDDY WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WOODBURN RD
ANNANDALE VA
22003-1202
US

IV. Provider business mailing address

3300 WOODBURN RD
ANNANDALE VA
22003-1202
US

V. Phone/Fax

Practice location:
  • Phone: 703-205-9452
  • Fax: 703-208-0714
Mailing address:
  • Phone: 703-205-9452
  • Fax: 703-208-0714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101232930
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: