Provider Demographics
NPI:1093825994
Name:WILSON, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-2703
Mailing Address - Country:US
Mailing Address - Phone:330-637-6000
Mailing Address - Fax:330-637-6002
Practice Address - Street 1:230 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-2703
Practice Address - Country:US
Practice Address - Phone:330-637-6000
Practice Address - Fax:330-637-6002
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000438OtherLICENSE #