Provider Demographics
NPI:1215978754
Name:WILSON, JEFFREY KENT (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KENT
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 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:8200 MEADOWBRIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2331
Practice Address - Country:US
Practice Address - Phone:804-730-2121
Practice Address - Fax:804-730-0563
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101035718207XS0114X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006403379Medicaid
VA285655OtherSOUTHERN HEALTH
VA32147OtherSH CARENET
VA540885859OtherCORVEL
VA1215978754Medicaid
VA540885859OtherFOCUS
VA540885859OtherPRIVATE HEALTHCARE SYSTEM
VA0900108OtherUNITED HEALTHCARE
VA540885859OtherCOMPMANAGEMENT
VA05367828OtherAETNA HMO
VA200020605OtherRAILROAD MEDICARE
VA46427OtherOPTIMA HEALTH
VA540885859OtherC&O EMPLOYEES HEALTHCARE
VA052664OtherANTHEM HEALTHKEEPERS
VA540885859OtherFIRST HEALTH/CCN
VA2138346OtherUNITED HEALTHCARE MAMSI
VA386544OtherANTHEM WEST END OPERATORY
VA540885859OtherCIGNA
VA200020605OtherRAILROAD MEDICARE
VA540885859OtherC&O EMPLOYEES HEALTHCARE
VA540885859OtherCOMPMANAGEMENT