MEDICARE: DR. MASAO ROY WILSON M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	45762	CO
2	207W00000X	Ophthalmology Physician	4301104424	MI

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8G7983	OTHER	TX	BC/BS
2	D005	OTHER	NM	TRIWEST
3	101767100	OTHER	TX	FIRSTCARE COMMERCIAL
4	82915	OTHER	NM	PRESBYTERIAN COMMERCIAL
5	87458Z	OTHER	TX	HMO BLUE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1932190782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MASAO ROY WILSON M.D.

Provider Business Mailing Address
First Line	:	400 MACK AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2136
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4717 SAINT ANTOINE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-1423
Country	:	US
Telephone Number	:	313-577-8900
Fax Number	:

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

Provider Enumeration Date	:	11/01/2005
Last Update Date	:	02/12/2025

4717 SAINT ANTOINE ST
DETROIT, MI
48201-1423

Practice Phone: 313-577-8900
Practice Fax:

4717 ST. ANTOINE , KRESGE EYE INSTITUTE
DETROIT, MI
48201-1423