Provider Demographics
NPI:1598830119
Name:WILSON, MICHAELYN (MD)
Entity Type:Individual
Prefix:MRS
First Name:MICHAELYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8641 WILSHIRE BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211
Mailing Address - Country:US
Mailing Address - Phone:310-659-6210
Mailing Address - Fax:310-659-5185
Practice Address - Street 1:8641 WILSHIRE BLVD
Practice Address - Street 2:STE 102
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211
Practice Address - Country:US
Practice Address - Phone:310-659-6210
Practice Address - Fax:310-659-5185
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79379207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G56996Medicare UPIN