Provider Demographics
NPI:1184666091
Name:WILSON, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:WILSON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:5 BURNETT AVENUE NORTH
Mailing Address - Street 2:APT. #1
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131
Mailing Address - Country:US
Mailing Address - Phone:415-642-9196
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVENUE
Practice Address - Street 2:SFGH DEPARTMENT OF RADIOLOGY, ROOM 1X57
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2204
Practice Address - Country:US
Practice Address - Phone:415-353-1300
Practice Address - Fax:415-353-8570
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-07-23
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Provider Licenses
StateLicense IDTaxonomies
CAG740732085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G740730Medicaid
CAG34001Medicare UPIN
CA00G740730Medicare PIN