Provider Demographics
NPI:1376535708
Name:WILSON, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:WRIGHT BLDG #301
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-340-4566
Mailing Address - Fax:760-340-2481
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:WRIGHT BLDG #301
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-340-4566
Practice Address - Fax:760-340-2481
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-06-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301063104207Y00000X
CAC135134207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA148759OtherMCAR PTAN
MI30036OtherHEALTH PLAN OF MICHIGAN
MI407001921OtherBCBS PROVIDER ID
MI442264310Medicaid
MIMW063104OtherBCBS
CACA148759OtherMCAR PTAN
MIH06769Medicare UPIN