Provider Demographics
NPI:1154352060
Name:WILSON, MARC A (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N BONNIE BRAE STREET
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201
Mailing Address - Country:US
Mailing Address - Phone:940-484-7100
Mailing Address - Fax:940-484-7101
Practice Address - Street 1:323 N BONNIE BRAE STREET
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201
Practice Address - Country:US
Practice Address - Phone:940-484-7100
Practice Address - Fax:940-484-7101
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0704207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144688203Medicaid
TX8F3762Medicare PIN