Provider Demographics
NPI:1952750465
Name:WILSON, MICHAEL E (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-234-1971
Mailing Address - Fax:304-830-5687
Practice Address - Street 1:1000 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-234-1971
Practice Address - Fax:304-830-5687
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0357757Medicaid