Provider Demographics
NPI:1417914813
Name:WILSON, MICHAEL R (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:1300 E ZION RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5015
Mailing Address - Country:US
Mailing Address - Phone:479-521-8980
Mailing Address - Fax:479-521-8982
Practice Address - Street 1:1300 E ZION RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5015
Practice Address - Country:US
Practice Address - Phone:479-521-8980
Practice Address - Fax:479-521-8982
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3255208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146880001Medicaid
AR5M157Medicare ID - Type Unspecified
H58409Medicare UPIN