Basic Information
| Provider Information | |||||||||
| NPI: | 1023269172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035251914 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2008 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N8874 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 7150810-1205 | UT | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1G4019 | 01 | TX | MEDICARE | OTHER | 751976930005 | 01 | TX | TRICARE -JACKSONVILLE | OTHER | 8X8164 | 01 | TX | BCBS | OTHER | P01439634 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 280231602 | 05 | TX | MEDICAID | 750818167044 | 01 | TX | TRICARE | OTHER | 75-0818167-048 | 01 | TX | TRICARE | OTHER | 8EY087 | 01 | TX | BCBS | OTHER | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 750818167022 | 01 | TX | TRICARE | OTHER | 280231601 | 05 | TX | MEDICAID | 75-0818167-015 | 01 | TX | TRICARE | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 8CS712 | 01 | TX | BCBS | OTHER | 8CT074 | 01 | TX | BCBS | OTHER |