MEDICARE: DR. TODD EUGENE 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	2085R0202X	Diagnostic Radiology Physician	4301407466	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780698910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TODD EUGENE WILSON MD

Provider Business Mailing Address
First Line	:	10850 E TRAVERSE HWY
Second Line	:	SUITE 60
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-1364
Country	:	US
Telephone Number	:	231-935-0499
Fax Number	:

Provider Business Practice Location Address
First Line	:	10850 E TRAVERSE HWY
Second Line	:	SUITE 60
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-1364
Country	:	US
Telephone Number	:	231-935-0499
Fax Number	:

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

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	07/08/2007

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