Provider Demographics
NPI:1972617793
Name:WILSON, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
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 1:311 CAMDEN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-2012
Mailing Address - Country:US
Mailing Address - Phone:210-281-9800
Mailing Address - Fax:
Practice Address - Street 1:311 CAMDEN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-2012
Practice Address - Country:US
Practice Address - Phone:210-281-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041702207RC0000X
TXP8096207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVAD000Medicare UPIN
TX332465YZ43Medicare PIN