Provider Demographics
NPI:1134324791
Name:WILSON, MICHAEL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1500 OWENS ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2334
Mailing Address - Country:US
Mailing Address - Phone:414-353-2069
Mailing Address - Fax:415-353-2633
Practice Address - Street 1:1500 OWENS ST
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-2334
Practice Address - Country:US
Practice Address - Phone:414-353-2069
Practice Address - Fax:415-353-2633
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2013-09-03
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Provider Licenses
StateLicense IDTaxonomies
CAA1253972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA002289502Medicare PIN