Provider Demographics
NPI:1831156355
Name:WILSON, MARK ALAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 STURBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-8515
Mailing Address - Country:US
Mailing Address - Phone:412-630-9779
Mailing Address - Fax:
Practice Address - Street 1:112 UNIVERSITY DRIVE C
Practice Address - Street 2:VA PITTSBURGH HEALTHCARE SYSTEM
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15240-1004
Practice Address - Country:US
Practice Address - Phone:412-688-6359
Practice Address - Fax:412-688-6683
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24719208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA670899Medicare ID - Type UnspecifiedVA MEDICARE
PAVAD000Medicare UPIN