Provider Demographics
NPI:1992711964
Name:WILSON, SALLY KING (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:KING
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 S COCHRAN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1568
Mailing Address - Country:US
Mailing Address - Phone:517-543-9095
Mailing Address - Fax:517-543-3339
Practice Address - Street 1:121 S COCHRAN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1568
Practice Address - Country:US
Practice Address - Phone:517-543-9095
Practice Address - Fax:517-543-3339
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H04209Medicare UPIN
MI0N94920Medicare ID - Type Unspecified