Johnny M Wilson, M.D.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

L4177 Issued in TX

Practice address

136 El Chico TRL
Suite 103
Willow Park, TX 76087-8863

Phone

(817) 441-1441

Fax

(817) 441-1443

NPI assigned

Aug 25, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 9

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1124928000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1269820800000",
    "number": "1114910080",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "136 EL CHICO TRL",
            "address_2": "SUITE 103",
            "city": "WILLOW PARK",
            "state": "TX",
            "postal_code": "760878863",
            "telephone_number": "817-441-1441",
            "fax_number": "817-441-1443"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "136 EL CHICO TRL",
            "address_2": "SUITE 103",
            "city": "WILLOW PARK",
            "state": "TX",
            "postal_code": "760878863",
            "telephone_number": "817-441-1441",
            "fax_number": "817-441-1443"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "JOHNNY",
        "middle_name": "M",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-08-25",
        "last_updated": "2010-03-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "L4177",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AFFILIATED HEALTHCARE",
            "identifier": "1164502",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNICARE",
            "identifier": "L4177",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "0072KC",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE LINK",
            "identifier": "0082174",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FOCUS",
            "identifier": "1354278",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA/TRS COORDINATED CAR",
            "identifier": "7111148",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "158350203",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "158350201",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CHIP HEALTHPLAN",
            "identifier": "WILJC67146",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Hannah Wilke, DC
• Tina Ann Wilkinson Moore, PA
• Jessica Danielle Williams, DO
• Willow Park Endoscopy Center, LLC
• Willow Park Home Health Care Services, Inc.
• Braden Alexander Wood
• Kayla Wood
• Russell S Wood, PH.D.
• Wpal 2015 LLC
• Tifani Leigh Yancey, PTA

• Family Medicine Physician in Willow Park, TX
• Providers in Willow Park, TX by specialty
• Family Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 29, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.