Provider Demographics
NPI:1053494559
Name:WILSON, CHRISTOPHER S (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-649-3240
Mailing Address - Fax:414-385-2481
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 575
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-5200
Practice Address - Country:US
Practice Address - Phone:414-649-3240
Practice Address - Fax:414-385-2481
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40285208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32453700Medicaid
WI000101329Medicare PIN
WI32453700Medicaid