Provider Demographics
NPI:1609827526
Name:BENGGON, WILSON (DO)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:BENGGON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:
Practice Address - Street 1:4665 DOUGLAS CIR NW
Practice Address - Street 2:SUITE 101
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3673
Practice Address - Country:US
Practice Address - Phone:330-499-5700
Practice Address - Fax:330-498-4229
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005106207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050084685OtherMEDICARE RAILROAD
000000212311OtherANTHEM
OH0926690Medicaid
000000212311OtherANTHEM
OH0926690Medicaid