Provider Demographics
NPI:1871537308
Name:WILSON, JOHN STARKS JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:STARKS
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:
Practice Address - Street 1:1783 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3205
Practice Address - Country:US
Practice Address - Phone:650-696-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG274832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G274830Medicaid
CA300087076OtherRAILROAD MEDICARE
CABG915ZMedicare PIN
CA300087076OtherRAILROAD MEDICARE
CA00G274834Medicare PIN
CA00G274830Medicare PIN
CA00G274833Medicare PIN
CA00G274832Medicare PIN
CA00G274831Medicare PIN