Provider Demographics
NPI:1831455450
Name:WILSON, MARK R (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
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 1:655 W 8TH ST
Mailing Address - Street 2:UF COLLEGE OF MEDICINE - JACKSONVILLE 2ND FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22971 HIGHWAY 76 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7529
Practice Address - Country:US
Practice Address - Phone:864-833-3046
Practice Address - Fax:864-833-1711
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51989207X00000X
MS24897207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery