Provider Demographics
NPI:1437177847
Name:WILSON, MELISA (MD)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 CAHABA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35223-2623
Mailing Address - Country:US
Mailing Address - Phone:205-870-7292
Mailing Address - Fax:205-870-3639
Practice Address - Street 1:3300 CAHABA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35223-2623
Practice Address - Country:US
Practice Address - Phone:205-870-7292
Practice Address - Fax:205-870-3639
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000008269Medicaid
AL51008269OtherBLUE CROSS BLUE SHIELD
AL51008269OtherBLUE CROSS BLUE SHIELD
H02559Medicare UPIN