Individual
FREDERICK MIKE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2613 FAIRWAY DR, FULTON, MO 65251
(573) 642-4242
Mailing address
PO BOX 1027, JEFFERSON CITY, MO 65102-1027
(573) 761-7246
(573) 761-6947
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
113229
MO
207R00000X
Internal Medicine Physician
Primary
113229
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
207326307
—
MO
Enumeration date
07/03/2006
Last updated
02/10/2015
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