Provider Demographics
NPI:1801860572
Name:WILSON, MARCIETTA R (DO)
Entity Type:Individual
Prefix:
First Name:MARCIETTA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 KOLBE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1652
Mailing Address - Country:US
Mailing Address - Phone:440-960-3912
Mailing Address - Fax:440-960-3913
Practice Address - Street 1:3600 KOLBE RD STE 210
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1652
Practice Address - Country:US
Practice Address - Phone:440-960-3912
Practice Address - Fax:440-960-3913
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11852207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007282000Medicaid
OH2493869Medicaid
OH0236248Medicaid
I11426Medicare UPIN
OH0236248Medicaid
OH2493869Medicaid
OH9284951Medicare PIN