Individual
DR. MARK D WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
39000 BOB HOPE DR, WRIGHT BLDG #301, RANCHO MIRAGE, CA 92270-3221
(760) 340-4566
(760) 340-2481
Mailing address
39000 BOB HOPE DR, WRIGHT BLDG #301, RANCHO MIRAGE, CA 92270-3221
(760) 340-4566
(760) 340-2481
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
4301063104
MI
207Y00000X
Otolaryngology Physician
Primary
C135134
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
30036
HEALTH PLAN OF MICHIGAN
MI
01
—
407001921
BCBS PROVIDER ID
MI
05
—
442264310
—
MI
01
—
CA148759
MCAR PTAN
CA
01
—
MW063104
BCBS
MI
Enumeration date
08/22/2005
Last updated
06/26/2015
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