Provider Demographics
NPI:1841251055
Name:WILSON, JEFFREY SCOTT (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
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 1:13085 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0926
Mailing Address - Country:US
Mailing Address - Phone:813-971-3064
Mailing Address - Fax:
Practice Address - Street 1:13085 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0926
Practice Address - Country:US
Practice Address - Phone:813-971-3064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1019632086S0127X
FLME1019632086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000293800Medicaid
FL59056OtherBLUE CROSS BLUE SHIELD
FL000293800Medicaid