Provider Demographics
NPI:1902819782
Name:WILSON, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 62106
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93160-2106
Mailing Address - Country:US
Mailing Address - Phone:805-681-1761
Mailing Address - Fax:805-681-1768
Practice Address - Street 1:215 PESETAS LN
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1416
Practice Address - Country:US
Practice Address - Phone:805-681-1761
Practice Address - Fax:805-681-1768
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA76968207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI36283Medicare UPIN
CAWA76968AMedicare ID - Type UnspecifiedWR211
CAWA76968BMedicare ID - Type UnspecifiedWR211A