Basic Information
| Provider Information | |||||||||
| NPI: | 1407892631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 EOFF ST | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042348663 | ||||||||
| FaxNumber: | 3042348960 | ||||||||
| Practice Location | |||||||||
| Address1: | 1132 NATIONAL RD | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260035940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042421032 | ||||||||
| FaxNumber: | 3042426341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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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 | 207R00000X | 2098 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2665272 | 05 | OH | MEDICAID | 3810005848 | 05 | WV | MEDICAID |