Provider Demographics
NPI:1144214842
Name:WILSON, ELIZABETH K (DO)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3011 N LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-9312
Mailing Address - Country:US
Mailing Address - Phone:906-786-6488
Mailing Address - Fax:906-786-6409
Practice Address - Street 1:3011 N LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-9312
Practice Address - Country:US
Practice Address - Phone:906-786-6488
Practice Address - Fax:906-786-6409
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080052892OtherRAILROAD MEDICARE
MI2966412Medicaid
MIE95959Medicare UPIN
MIOP383400013Medicare Oscar/Certification
MI080052892OtherRAILROAD MEDICARE
MI2966412Medicaid