Provider Demographics
NPI:1740229293
Name:WILSON, MICHAEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:1600 E CITRUS AVE
Practice Address - Street 2:STE A
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4270
Practice Address - Country:US
Practice Address - Phone:909-794-3682
Practice Address - Fax:909-796-4158
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G751591Medicaid
CA00G751591Medicaid