Provider Demographics
NPI:1760410997
Name:WILSON, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
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 2648
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-2648
Mailing Address - Country:US
Mailing Address - Phone:205-558-2158
Mailing Address - Fax:205-930-1575
Practice Address - Street 1:1400 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1502
Practice Address - Country:US
Practice Address - Phone:205-558-2158
Practice Address - Fax:205-930-1575
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15807207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000089050Medicaid
AL89050Medicare ID - Type Unspecified
AL000089050Medicaid