Provider Demographics
NPI:1356769186
Name:WILSON, DUNCAN
Entity type:Individual
Prefix:
First Name:DUNCAN
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 1:1212 S MICHIGAN AVE
Mailing Address - Street 2:APT 2808
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2416
Mailing Address - Country:US
Mailing Address - Phone:703-851-3584
Mailing Address - Fax:
Practice Address - Street 1:240 E HURON ST
Practice Address - Street 2:SUITE 1-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2909
Practice Address - Country:US
Practice Address - Phone:703-851-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-29
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125064410207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program