Provider Demographics
NPI:1295728087
Name:WILSON, MARK MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:MATTHEW
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 1:1337 CENTRE CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3405
Mailing Address - Country:US
Mailing Address - Phone:318-445-9331
Mailing Address - Fax:318-619-6899
Practice Address - Street 1:1337 CENTRE CT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-445-9331
Practice Address - Fax:318-619-6899
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019488207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1934780Medicaid
LAE13611Medicare UPIN
LA1934780Medicaid