Provider Demographics
NPI:1073707626
Name:WESLEY G. WILSON, D.O., P.A.
Entity type:Organization
Organization Name:WESLEY G. WILSON, D.O., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-564-0711
Mailing Address - Street 1:713 W BROAD #200
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-9107
Mailing Address - Country:US
Mailing Address - Phone:972-564-0711
Mailing Address - Fax:972-564-0323
Practice Address - Street 1:713 W BROAD #200
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-9107
Practice Address - Country:US
Practice Address - Phone:972-564-0711
Practice Address - Fax:972-564-0323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0038MMedicare PIN