Provider Demographics
NPI:1255340337
Name:WILSON, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:612 N ANDOVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-9778
Practice Address - Country:US
Practice Address - Phone:316-733-6618
Practice Address - Fax:316-733-5299
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS25289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2807OtherPHS
KS041801OtherBCBS
KS100842OtherHPK
KS16949OtherCOVENTRY
KS11084898OtherMULTIPLAN
KS11084898OtherMULTIPLAN
KS041801Medicare ID - Type Unspecified