Provider Demographics
NPI:1962039958
Name:WILSON, ALPHONSO
Entity type:Individual
Prefix:
First Name:ALPHONSO
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 SEALOFTS DR APT 202
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-3739
Mailing Address - Country:US
Mailing Address - Phone:904-254-0812
Mailing Address - Fax:
Practice Address - Street 1:4800 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-8413
Practice Address - Country:US
Practice Address - Phone:870-936-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-16711207R00000X
FL156192207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine