Provider Demographics
NPI:1649232943
Name:WILSON, MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:813 HOLLY HEDGE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-9664
Mailing Address - Country:US
Mailing Address - Phone:336-946-2729
Mailing Address - Fax:336-946-2729
Practice Address - Street 1:190 KIMEL PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-768-3296
Practice Address - Fax:336-794-8668
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist