Provider Demographics
NPI:1932190782
Name:WILSON, MASAO ROY (MD)
Entity type:Individual
Prefix:DR
First Name:MASAO
Middle Name:ROY
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 1:400 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4717 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1423
Practice Address - Country:US
Practice Address - Phone:313-577-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45762207W00000X
MI4301104424207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G7983OtherBC/BS
NMD005OtherTRIWEST
TX101767100OtherFIRSTCARE COMMERCIAL
NM82915OtherPRESBYTERIAN COMMERCIAL
TX87458ZOtherHMO BLUE
TX164556601Medicaid
TX101767101Medicaid
OK200016600AMedicaid
MI1932190782Medicaid
NM74528319Medicaid
NM82915Medicaid