Provider Demographics
NPI:1285622365
Name:WILSON, JAMES CORNELIUS III
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:CORNELIUS
Last Name:WILSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:CORNELIUS
Other - Last Name:WILSON
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:68 WARE ST
Mailing Address - Street 2:
Mailing Address - City:WEST BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01585-3136
Mailing Address - Country:US
Mailing Address - Phone:508-867-8977
Mailing Address - Fax:
Practice Address - Street 1:46 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST BROOKFIELD
Practice Address - State:MA
Practice Address - Zip Code:01585-3232
Practice Address - Country:US
Practice Address - Phone:508-867-8977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2096200Medicaid
MA2096200Medicaid
MAA37776Medicare ID - Type Unspecified