Provider Demographics
NPI:1124097282
Name:WILSON, JOAN (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 EXECUTIVE DR
Mailing Address - Street 2:STE E
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4160
Mailing Address - Country:US
Mailing Address - Phone:434-572-8921
Mailing Address - Fax:434-572-2063
Practice Address - Street 1:2212 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1630
Practice Address - Country:US
Practice Address - Phone:434-572-8921
Practice Address - Fax:434-572-2063
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034828207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA240940OtherBCBS
VA006207561Medicaid
VA48092OtherOPTIMA
VA240940OtherBCBS
VA48092OtherOPTIMA