Basic Information
| Provider Information | |||||||||
| NPI: | 1215978754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | KENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045605595 | ||||||||
| FaxNumber: | 8045609029 | ||||||||
| Practice Location | |||||||||
| Address1: | 8200 MEADOWBRIDGE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231162331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047302121 | ||||||||
| FaxNumber: | 8047300563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | 101035718 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207X00000X | 101035718 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 006403379 | 05 | VA | MEDICAID | 285655 | 01 | VA | SOUTHERN HEALTH | OTHER | 32147 | 01 | VA | SH CARENET | OTHER | 540885859 | 01 | VA | CORVEL | OTHER | 1215978754 | 05 | VA | MEDICAID | 540885859 | 01 | VA | FOCUS | OTHER | 540885859 | 01 | VA | PRIVATE HEALTHCARE SYSTEM | OTHER | 0900108 | 01 | VA | UNITED HEALTHCARE | OTHER | 540885859 | 01 | VA | COMPMANAGEMENT | OTHER | 05367828 | 01 | VA | AETNA HMO | OTHER | 200020605 | 01 | VA | RAILROAD MEDICARE | OTHER | 46427 | 01 | VA | OPTIMA HEALTH | OTHER | 540885859 | 01 | VA | C&O EMPLOYEES HEALTHCARE | OTHER | 052664 | 01 | VA | ANTHEM HEALTHKEEPERS | OTHER | 540885859 | 01 | VA | FIRST HEALTH/CCN | OTHER | 2138346 | 01 | VA | UNITED HEALTHCARE MAMSI | OTHER | 386544 | 01 | VA | ANTHEM WEST END OPERATORY | OTHER | 540885859 | 01 | VA | CIGNA | OTHER |