Healthcare Provider Details

I. General information

NPI: 1326090739
Provider Name (Legal Business Name): JAMES T WILSON III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HIGHLAND AVE SE SUITE 104
ROANOKE VA
24013-2256
US

IV. Provider business mailing address

8039 VISTA FOREST DR
ROANOKE VA
24018-5707
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-8454
  • Fax: 540-985-8345
Mailing address:
  • Phone: 540-985-8454
  • Fax: 540-985-8345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number0101034644
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: