Provider Demographics
NPI:1801865860
Name:WILSON, WILLIAM M (MD MBBS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1852
Mailing Address - Country:US
Mailing Address - Phone:262-473-0400
Mailing Address - Fax:262-473-0408
Practice Address - Street 1:507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1852
Practice Address - Country:US
Practice Address - Phone:262-473-0400
Practice Address - Fax:262-473-0408
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35017-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801865860Medicaid