MEDICARE: JAMES P WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME0039417	FL

General Provider Information

NPI Number	:	1023027315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAMES P WILSON MD

Provider Business Mailing Address
First Line	:	203 CLOVERDALE BLVD
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1405
Country	:	US
Telephone Number	:	850-862-7604
Fax Number	:	850-862-8156

Provider Business Practice Location Address
First Line	:	203 CLOVERDALE BLVD
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1405
Country	:	US
Telephone Number	:	850-862-7604
Fax Number	:	850-862-8156

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	HEATHER WILSON
Credential	:
Telephone Number	:	850-862-7604

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	01/23/2013

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