Provider Demographics
NPI:1750736088
Name:WILSON, MARK
Entity type:Individual
Prefix:MR
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 1:5313 OGDEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-1438
Mailing Address - Country:US
Mailing Address - Phone:215-600-9477
Mailing Address - Fax:215-921-8499
Practice Address - Street 1:5313 OGDEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-1438
Practice Address - Country:US
Practice Address - Phone:215-600-9477
Practice Address - Fax:215-921-8499
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-23
Last Update Date:2016-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAA-6418104261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center