Provider Demographics
NPI:1518313089
Name:WILSON, MARK (IDMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:ALLEN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IDMT
Mailing Address - Street 1:2200 MAMMOTH WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2611
Mailing Address - Country:US
Mailing Address - Phone:502-472-1274
Mailing Address - Fax:
Practice Address - Street 1:1101 GRADE LN
Practice Address - Street 2:123 SPECIAL TACTICS
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-2673
Practice Address - Country:US
Practice Address - Phone:502-413-4836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians