Healthcare Provider Details

I. General information

NPI: 1518578202
Provider Name (Legal Business Name): MICHAEL ANTHONY WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14400 NW 77TH CT STE 306
MIAMI LAKES FL
33016-1592
US

IV. Provider business mailing address

14400 NW 77TH CT STE 306
MIAMI LAKES FL
33016-1592
US

V. Phone/Fax

Practice location:
  • Phone: 305-653-5155
  • Fax: 305-653-5513
Mailing address:
  • Phone: 305-653-5155
  • Fax: 305-653-5513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME159174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: