Provider Demographics
NPI:1639673924
Name:WILSON, JOHN MICHAEL
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:393-433-8002
Mailing Address - Fax:239-343-4261
Practice Address - Street 1:632 DEL PRADO BLVD N
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2278
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-4261
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA326172208D00000X
390200000X
FLME173577207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL127244600Medicaid