Provider Demographics
NPI:1568402121
Name:WILSON, MARK CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTOPHER
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 KANLOW DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3951
Mailing Address - Country:US
Mailing Address - Phone:615-941-5204
Mailing Address - Fax:
Practice Address - Street 1:2025 VIRGINIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2921
Practice Address - Country:US
Practice Address - Phone:615-585-5941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000039499207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine