Provider Demographics
NPI:1356323786
Name:WILSON, MARK COOPER (MD MPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:COOPER
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-4241
Mailing Address - Fax:319-356-3086
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:319-356-4241
Practice Address - Fax:319-356-3086
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35455207R00000X
IAMD-35455208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA04278OtherWELLMARK BCBS
IA0431981Medicaid
IA04278OtherWELLMARK BCBS
IA0431981Medicaid
C87218Medicare UPIN