Healthcare Provider Details

I. General information

NPI: 1801865860
Provider Name (Legal Business Name): WILLIAM M. WILSON MD MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 W MAIN ST
WHITEWATER WI
53190-1852
US

IV. Provider business mailing address

507 W MAIN ST
WHITEWATER WI
53190-1852
US

V. Phone/Fax

Practice location:
  • Phone: 262-473-0400
  • Fax: 262-473-0408
Mailing address:
  • Phone: 262-473-0400
  • Fax: 262-473-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35017-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: