1629052238 NPI number — MR. MICHAEL E. WILSON DO

Table of content: EMILY DIAZ ACEVEDO MSN, ARNP-FNP (NPI 1013453810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629052238 NPI number — MR. MICHAEL E. WILSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
MICHAEL
Provider Middle Name:
E.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629052238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22075
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97269-2075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-659-4777
Provider Business Mailing Address Fax Number:
503-652-5223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12360 SE SUNNYSIDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-9320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-659-4988
Provider Business Practice Location Address Fax Number:
503-698-4018
Provider Enumeration Date:
12/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  DO18900 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00036570 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 079983 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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