Provider Demographics
NPI:1013981596
Name:WILSON, MARLA KAY (DPM)
Entity type:Individual
Prefix:DR
First Name:MARLA
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2549
Mailing Address - Country:US
Mailing Address - Phone:217-522-3622
Mailing Address - Fax:217-522-3046
Practice Address - Street 1:1522 S 5TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2549
Practice Address - Country:US
Practice Address - Phone:217-522-3622
Practice Address - Fax:217-522-3046
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004880213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1626545OtherBLUE CROSS BLUE SHIELD
IL203265Medicare ID - Type UnspecifiedMONTGOMERY COUNTY
ILU78174Medicare UPIN
IL203264Medicare ID - Type UnspecifiedSANGAMON COUNTY