Provider Demographics
NPI:1821026436
Name:WILSON, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2000 EOFF ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3823
Mailing Address - Country:US
Mailing Address - Phone:304-234-8663
Mailing Address - Fax:304-234-8960
Practice Address - Street 1:135 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-1586
Practice Address - Country:US
Practice Address - Phone:740-695-9470
Practice Address - Fax:740-695-3674
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35080667208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV184037700Medicaid
OH2302672Medicaid
WV184037700Medicaid
OHH246220Medicare PIN
OH2302672Medicaid