Provider Demographics
NPI:1073722252
Name:WILSON, MICHAEL THOMAS (CPO LPO FAAOP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:CPO LPO FAAOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 CARTWRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2602
Mailing Address - Country:US
Mailing Address - Phone:281-403-0107
Mailing Address - Fax:
Practice Address - Street 1:2711 CARTWRIGHT RD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2602
Practice Address - Country:US
Practice Address - Phone:281-403-0107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX584332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXZ05085353Medicaid
TX0429180001Medicare ID - Type Unspecified