Provider Demographics
NPI:1629052238
Name:WILSON, MICHAEL E (DO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22075
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2075
Mailing Address - Country:US
Mailing Address - Phone:503-659-4777
Mailing Address - Fax:503-652-5223
Practice Address - Street 1:12360 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9320
Practice Address - Country:US
Practice Address - Phone:503-659-4988
Practice Address - Fax:503-698-4018
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO18900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00036570OtherRR MEDICARE
OR079983Medicaid
ORP00036570OtherRR MEDICARE
ORG26882Medicare UPIN