Provider Demographics
NPI:1881802288
Name:WILSON, RONALD EUGENE (DPM)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:EUGENE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18460 REVERE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1726
Mailing Address - Country:US
Mailing Address - Phone:313-865-4400
Mailing Address - Fax:313-865-4400
Practice Address - Street 1:18460 REVERE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1726
Practice Address - Country:US
Practice Address - Phone:313-865-4400
Practice Address - Fax:313-865-4400
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2025-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI59-010-01377213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI131753526Medicaid
MI4858211610OtherBCBS PIN
MI4858211610OtherBCBS PIN
MIT34357Medicare UPIN