Healthcare Provider Details

I. General information

NPI: 1457194425
Provider Name (Legal Business Name): VICTORIA WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

4757 RAVENSWOOD DR SW
GRANDVILLE MI
49418-2284
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6922
  • Fax: 616-685-5192
Mailing address:
  • Phone: 989-583-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351056427
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: