Provider Demographics
NPI:1164424743
Name:WILSON, KEITH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
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 1:10 DUTTON DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-1818
Mailing Address - Country:US
Mailing Address - Phone:330-746-7691
Mailing Address - Fax:330-743-8368
Practice Address - Street 1:10 DUTTON DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-1818
Practice Address - Country:US
Practice Address - Phone:330-746-7691
Practice Address - Fax:330-743-8368
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-052784207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH438220OtherKEYSTONE
OH82799OtherQUALCHOICE
OH0800328OtherUNITED HEALTHCARE
OH180011155OtherRAILROAD MEDICARE
OH4096251OtherAETNA
WV0095849000OtherMEDICAID
OH0624695Medicaid
OHZ52784OtherSUMMACARE
OH000000126322OtherANTHEM
OHZ52784OtherSUMMACARE
OH0580941Medicare ID - Type UnspecifiedMEDICARE PPIN