Provider Demographics
NPI:1992792774
Name:WILSON, MICHAEL LEON (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEON
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7680
Mailing Address - Country:US
Mailing Address - Phone:530-895-3668
Mailing Address - Fax:503-895-0927
Practice Address - Street 1:2103 FOREST AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-7680
Practice Address - Country:US
Practice Address - Phone:530-895-3668
Practice Address - Fax:503-895-0927
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4344213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43440Medicare PIN
CAU88368Medicare UPIN
CA5875170001Medicare NSC