Provider Demographics
NPI:1174006381
Name:WILSON, PETER
Entity type:Individual
Prefix:
First Name:PETER
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 1:4392 INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-2226
Mailing Address - Country:US
Mailing Address - Phone:614-725-2488
Mailing Address - Fax:614-725-2302
Practice Address - Street 1:4392 INDIANOLA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2226
Practice Address - Country:US
Practice Address - Phone:614-725-2488
Practice Address - Fax:614-725-2302
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65.000323171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH65.000323OtherACUPUNCTURIST LICENSE # (OHIO STATE MEDICAL BOARD)
157884OtherDIPL. AC. (NCCAOM)