Provider Demographics
NPI:1710949581
Name:WILSON, MELINDA KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 S 70TH ST
Mailing Address - Street 2:SUITE N500
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3151
Mailing Address - Country:US
Mailing Address - Phone:414-455-4780
Mailing Address - Fax:414-475-2936
Practice Address - Street 1:311 STRAIGHT ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219
Practice Address - Country:US
Practice Address - Phone:513-559-2260
Practice Address - Fax:513-475-5258
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064665W2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0917048Medicaid
KY64932288Medicaid
IN100386530Medicaid
WI0736415OtherPTAN
OHWI0736413Medicare PIN
OH0917048Medicaid
OH0736416Medicare PIN
IN172710JMedicare PIN
IN100386530Medicaid