Provider Demographics
NPI:1609073204
Name:WILSON, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
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 1:401 MATTHEW ST
Mailing Address - Street 2:HOSPITALISTS GROUP
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-1635
Mailing Address - Country:US
Mailing Address - Phone:740-374-7700
Mailing Address - Fax:740-374-7701
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-376-1994
Practice Address - Fax:740-374-7701
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.125167208M00000X
WV23491208M00000X
OH35.126167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810017528Medicaid
OH3044860Medicaid
OHP01529303OtherRAILROAD MEDICARE
OH3044860Medicaid