Provider Demographics
NPI:1790768133
Name:WILSON, JEFFREY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
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 1:28905 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0923
Mailing Address - Country:US
Mailing Address - Phone:248-544-2293
Mailing Address - Fax:248-544-1624
Practice Address - Street 1:28905 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0923
Practice Address - Country:US
Practice Address - Phone:248-544-2293
Practice Address - Fax:248-544-1624
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033906207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1091529Medicaid
MI1091529Medicaid
B47313Medicare UPIN