Provider Demographics
NPI:1912098823
Name:PAUL M. WILSON, M.D., P.C.
Entity Type:Organization
Organization Name:PAUL M. WILSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-899-0373
Mailing Address - Street 1:4710 AUTH PL
Mailing Address - Street 2:SUITE #595
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-4223
Mailing Address - Country:US
Mailing Address - Phone:301-899-0373
Mailing Address - Fax:301-899-0375
Practice Address - Street 1:4710 AUTH PL
Practice Address - Street 2:SUITE #595
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-4223
Practice Address - Country:US
Practice Address - Phone:301-899-0373
Practice Address - Fax:301-899-0375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE57383Medicare UPIN