Provider Demographics
NPI:1568652147
Name:WILSON, MICHAEL DEAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
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 1:2500 METROHEALTH DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1900
Mailing Address - Country:US
Mailing Address - Phone:419-251-4340
Mailing Address - Fax:
Practice Address - Street 1:2500 METROHEALTH DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1900
Practice Address - Country:US
Practice Address - Phone:216-778-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND205302085R0202X
AZ410272085R0202X
OH350989532085R0202X
MI43010824262085R0202X
GUMC-1942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067456Medicaid
AZ378616Medicaid
OH35-098953OtherOHIO MEDICAL LICENSE
AZ378616Medicaid
OH35-098953OtherOHIO MEDICAL LICENSE