Provider Demographics
NPI:1609873330
Name:WILSON, MARK H (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1076 W CHANDLER BLVD
Mailing Address - Street 2:STE 113
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5225
Mailing Address - Country:US
Mailing Address - Phone:480-963-9334
Mailing Address - Fax:480-963-0444
Practice Address - Street 1:1076 W CHANDLER BLVD
Practice Address - Street 2:STE 113
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5225
Practice Address - Country:US
Practice Address - Phone:480-963-9334
Practice Address - Fax:480-963-0444
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-05-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ13278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ251166Medicaid
AZAZ0039000OtherBLUE CROSS BLUE SHIELD
AZD37851Medicare UPIN
AZ251166Medicaid