Jack T Wilson III, D.M.D.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

5247 Issued in KY

Practice address

12010 Shelbyville Rd
Suite 200
Louisville, KY 40243-1054

Phone

(502) 583-4771

Fax

(502) 584-9922

NPI assigned

Feb 21, 2007

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in KY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Tiva Oba, L.L.C.

  • Certified Registered Nurse Anesthetist
  • Louisville, KY
  • NPI 1740543990
  NPD (past)

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

{
    "created_epoch": "1172016000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1396880902",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12010 SHELBYVILLE RD",
            "address_2": "SUITE 200",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402431054",
            "telephone_number": "502-583-4771",
            "fax_number": "502-584-9922"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12010 SHELBYVILLE RD",
            "address_2": "SUITE 200",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402431054",
            "telephone_number": "502-583-4771",
            "fax_number": "502-584-9922"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON III",
        "first_name": "JACK",
        "middle_name": "T",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-02-21",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "KY",
            "license": "5247",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTIST - GENERAL PRACTIT",
            "identifier": "5247",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Rheagan Wills, PHARMD
• Neil Andrew Willsey, R.PH.
• Shari Rose Willy, RD, LDE
• Jessica Nicole Wilmore, MS, CCC-SLP
• Karen Louise Wilsman, AGNP
• Taylor Nicole Wilson Matthews
• Wilson Transportation
• Peyton Wilson-Camp
• Aaron Hugh Wilson, DMD
• Adrian S Wilson, DMD

• General Practice Dentistry in Louisville, KY
• Providers in Louisville, KY by specialty
• General Practice Dentistry in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.