Provider Demographics
NPI:1447256128
Name:WILSON, WESLEY GARRETT (DO)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:GARRETT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-4116
Mailing Address - Country:US
Mailing Address - Phone:469-720-4490
Mailing Address - Fax:833-450-4889
Practice Address - Street 1:605 E BROAD ST
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-4116
Practice Address - Country:US
Practice Address - Phone:469-720-4490
Practice Address - Fax:833-450-4889
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030193901Medicaid
TX030193901Medicaid
TX103973703Medicaid
TX103973704Medicaid
TX00386MMedicare PIN
TX103973704Medicaid
TX8K8872Medicare PIN
TX8K8871Medicare PIN
TX103973703Medicaid