Healthcare Provider Details

I. General information

NPI: 1184666091
Provider Name (Legal Business Name): MARK W. WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVENUE SFGH DEPARTMENT OF RADIOLOGY, ROOM 1X57
SAN FRANCISCO CA
94110-2204
US

IV. Provider business mailing address

5 BURNETT AVENUE NORTH APT. #1
SAN FRANCISCO CA
94131
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-1300
  • Fax: 415-353-8570
Mailing address:
  • Phone: 415-642-9196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG74073
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG74073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: