1376535708 NPI number — DR. MARK D WILSON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376535708 NPI number — DR. MARK D WILSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
MARK
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1376535708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39000 BOB HOPE DR
Provider Second Line Business Mailing Address:
WRIGHT BLDG #301
Provider Business Mailing Address City Name:
RANCHO MIRAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92270-3221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-340-4566
Provider Business Mailing Address Fax Number:
760-340-2481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39000 BOB HOPE DR
Provider Second Line Business Practice Location Address:
WRIGHT BLDG #301
Provider Business Practice Location Address City Name:
RANCHO MIRAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92270-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-340-4566
Provider Business Practice Location Address Fax Number:
760-340-2481
Provider Enumeration Date:
08/22/2005

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: 207Y00000X , with the licence number:  4301063104 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: C135134 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CA148759 . This is a "MCAR PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 30036 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 407001921 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 442264310 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: MW063104 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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