Provider Demographics
NPI:1992747034
Name:WILSON, JAMES BRADLEY JR (DO)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BRADLEY
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:DO
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Mailing Address - Street 1:17327 PAGONIA RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6009
Mailing Address - Country:US
Mailing Address - Phone:407-905-6009
Mailing Address - Fax:407-636-7849
Practice Address - Street 1:17327 PAGONIA RD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6009
Practice Address - Country:US
Practice Address - Phone:407-905-6009
Practice Address - Fax:407-636-7849
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-08-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS7986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS 7986OtherFLORIDA LISCENSE
H442254Medicare UPIN
FLOS 7986OtherFLORIDA LISCENSE