Provider Demographics
NPI:1558312900
Name:WILSON, VIRGINIA K (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:K
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 1:705 S UNIVERSITY AVE STE 510
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3081
Mailing Address - Country:US
Mailing Address - Phone:920-356-9288
Mailing Address - Fax:920-356-1835
Practice Address - Street 1:705 S UNIVERSITY AVE STE 510
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3081
Practice Address - Country:US
Practice Address - Phone:920-356-9288
Practice Address - Fax:920-356-1835
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35937-020207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558312900Medicaid
WI1558312900Medicaid
WIK400176824Medicare PIN
WI1042600OtherPHYSICIANS PLUS
WI660003607Medicare PIN
WI32076000Medicaid
MN070K5WIOtherBLUE CROSS BLUE SHIELD
E84471Medicare UPIN
WI006557155Medicare PIN