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General NPI Number Information
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NPI Number | 1376106120
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Entity Type | Individual
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Provider Name | JOHN WILSON MD
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Gender | Male
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Dates
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Enumeration Date | 04/17/2019
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Last Update Date | 08/27/2024
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Provider Practice Location Address
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Address Line | 4502 MEDICAL DR
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City | SAN ANTONIO
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State | TX
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Zip | 78229-4402
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Country | US
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Telephone | 210-358-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 403 FOSTER LN
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City | CANYON
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State | TX
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Zip | 79015-4229
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Country | US
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Telephone | 806-679-8720
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084F0202X
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Taxonomy Name | Forensic Psychiatry Physician
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License Number | D0096296
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | T3569
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License Number State | TX
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