Healthcare Provider Details

I. General information

NPI: 1679660682
Provider Name (Legal Business Name): MARK WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3134 BRIARCREST DR
BRYAN TX
77802-3014
US

IV. Provider business mailing address

17268 EAGLE PASS DR
COLLEGE STATION TX
77845-4567
US

V. Phone/Fax

Practice location:
  • Phone: 979-314-2323
  • Fax:
Mailing address:
  • Phone: 979-217-1317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberN1225
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: