Provider Demographics
NPI:1992123285
Name:WILSON, MARK (MOT OTR/L)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MOT OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 EL RANCHO DRIVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019
Mailing Address - Country:US
Mailing Address - Phone:619-607-4288
Mailing Address - Fax:
Practice Address - Street 1:2820 ROOSEVELT ROAD STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106
Practice Address - Country:US
Practice Address - Phone:619-607-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14125225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist