Provider Demographics
NPI:1184612368
Name:WILSON, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9513
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:601-326-3559
Practice Address - Street 1:971 LAKELAND DR STE 250
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4620
Practice Address - Country:US
Practice Address - Phone:601-200-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15570207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118644Medicaid
MS100000125Medicare PIN
MSF53898Medicare UPIN
MS00118644Medicaid