Basic Information
| Provider Information | |||||||||
| NPI: | 1801860572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MARCIETTA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 KOLBE RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409603912 | ||||||||
| FaxNumber: | 4409603913 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 KOLBE RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409603912 | ||||||||
| FaxNumber: | 4409603913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | OS11852 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 007282000 | 05 | FL | MEDICAID | 2493869 | 05 | OH | MEDICAID | 0236248 | 05 | OH | MEDICAID |