MEDICARE: MARY KATE WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	166739	FL
2	207WX0200X	Ophthalmic Plastic and Reconstructive Surgery Physician	ME166739	FL

General Provider Information

NPI Number	:	1750910949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATE WILSON MD

Provider Business Mailing Address
First Line	:	PO BOX 11407
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35246-8575
Country	:	US
Telephone Number	:	864-359-1308
Fax Number	:	239-496-3939

Provider Business Practice Location Address
First Line	:	206 ASHOURIAN AVE STE 215
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-5107
Country	:	US
Telephone Number	:	904-296-0098
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2020
Last Update Date	:	04/01/2026

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