Provider Demographics
NPI:1407973407
Name:WILSON, MICHAEL TODD (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TODD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5949 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3353
Mailing Address - Country:US
Mailing Address - Phone:614-367-9355
Mailing Address - Fax:614-501-6481
Practice Address - Street 1:5949 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3353
Practice Address - Country:US
Practice Address - Phone:614-367-9355
Practice Address - Fax:614-501-6481
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2162111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0107628Medicaid
OH4091041Medicare PIN