Provider Demographics
NPI:1871793570
Name:WILSON, IAN JERMAINE (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:JERMAINE
Last Name:WILSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E MOREHEAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 SPINDRIFT DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7891
Practice Address - Country:US
Practice Address - Phone:716-631-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361690122085R0202X, 2085R0204X
NY2446372085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02933948Medicaid
NY02933948Medicaid
NYRB6569Medicare PIN