Provider Demographics
NPI:1053456699
Name:WILSON, DAVID JAMES (DC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 VALLEY CREEK RD
Mailing Address - Street 2:STE 145
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-734-1123
Mailing Address - Fax:651-734-1109
Practice Address - Street 1:9900 VALLEY CREEK RD
Practice Address - Street 2:STE 145
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-734-1123
Practice Address - Fax:651-734-1109
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4269111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN260J9WIOtherBLUE CROSS BLUE SHIELD