Provider Demographics
NPI:1932677630
Name:WILSON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 KENNETH DR
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9252
Mailing Address - Country:US
Mailing Address - Phone:330-261-5009
Mailing Address - Fax:
Practice Address - Street 1:3975 KENNETH DR
Practice Address - Street 2:
Practice Address - City:ROOTSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44272-9252
Practice Address - Country:US
Practice Address - Phone:330-261-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator