Provider Demographics
NPI:1801814504
Name:WILCOX, MICHAEL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:WILCOX
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 1:310 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071-1403
Mailing Address - Country:US
Mailing Address - Phone:952-758-3090
Mailing Address - Fax:952-758-8053
Practice Address - Street 1:310 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-1403
Practice Address - Country:US
Practice Address - Phone:952-758-3090
Practice Address - Fax:952-758-8053
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20837207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN420872200Medicaid
MN420872200Medicaid
MND75651Medicare UPIN