Provider Demographics
NPI:1285070284
Name:WILSON, ALICIA MARIE (DO)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:MARIE
Other - Last Name:KECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3096
Mailing Address - Country:US
Mailing Address - Phone:574-233-7337
Mailing Address - Fax:574-239-1561
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-233-7337
Practice Address - Fax:574-239-1561
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004821A208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program