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General NPI Number Information
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NPI Number | 1679673560
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Entity Type | Individual
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Provider Name | JOHN DAVID WILSON MD
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Gender | Male
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 07/26/2018
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Provider Practice Location Address
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Address Line | 701 GROVE RD ER ADMINISTRATION
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City | GREENVILLE
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State | SC
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Zip | 29605
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Country | US
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Telephone | 864-455-6372
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Fax |
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Provider Business Mailing Address
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Address Line | 1 INDEPENDENCE PT STE 212
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City | GREENVILLE
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State | SC
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Zip | 29615-4536
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Country | US
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Telephone | 864-797-6174
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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 | 207PP0204X
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Taxonomy Name | Pediatric Emergency Medicine (Emergency Medicine) Physician
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License Number | 14469
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License Number State | SC
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