Provider Demographics
NPI:1902855455
Name:WILSON, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 BOWMAN DRIVE
Mailing Address - Street 2:STE 190
Mailing Address - City:VOORHEES TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9634
Mailing Address - Country:US
Mailing Address - Phone:856-247-7370
Mailing Address - Fax:856-247-7331
Practice Address - Street 1:200 BOWMAN DRIVE
Practice Address - Street 2:STE 190
Practice Address - City:VOORHEES TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08043-9634
Practice Address - Country:US
Practice Address - Phone:609-261-7074
Practice Address - Fax:856-247-7331
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4229152085R0001X
NJ25MA080526002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0128244Medicaid
NJ100869Medicare PIN
NJ0128244Medicaid