Provider Demographics
NPI:1326032343
Name:WILSON, EDWIN E (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:E
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 1:121 POPLAR CT
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-5013
Mailing Address - Country:US
Mailing Address - Phone:920-722-3494
Mailing Address - Fax:
Practice Address - Street 1:121 POPLAR CT
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-5013
Practice Address - Country:US
Practice Address - Phone:920-722-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30131600Medicaid
B57645Medicare UPIN
WI30131600Medicaid
WI0073 71018Medicare PIN