Provider Demographics
NPI:1063414720
Name:WILSON, BRIAN SEAN (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SEAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 CADIZ RD
Mailing Address - Street 2:
Mailing Address - City:WINTERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43953-7630
Mailing Address - Country:US
Mailing Address - Phone:740-264-6235
Mailing Address - Fax:740-264-9395
Practice Address - Street 1:1562 CADIZ RD
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-7630
Practice Address - Country:US
Practice Address - Phone:740-264-6235
Practice Address - Fax:740-264-9395
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2674111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2057983Medicaid
U70788Medicare UPIN
OHWI0846612Medicare ID - Type Unspecified