Provider Demographics
NPI:1124091566
Name:WILSON, JAMES ALLEN (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ALLEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95004
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-5004
Mailing Address - Country:US
Mailing Address - Phone:863-680-7206
Mailing Address - Fax:863-680-7420
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-680-7000
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36946208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048524100Medicaid
FL0471260001Medicare NSC
FL05964ZMedicare PIN
E82709Medicare UPIN