Provider Demographics
NPI:1063526507
Name:WILSON, ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:706-549-5981
Practice Address - Street 1:5440 HILLANDALE DR
Practice Address - Street 2:KAISER PERMANENTE PANOLA MEDICAL CENTER
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4865
Practice Address - Country:US
Practice Address - Phone:770-322-2777
Practice Address - Fax:706-549-5981
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00381917DMedicaid
GA481143OtherBCBS
GA00381917CMedicaid
GA4491297OtherAETNA
GA080184143OtherMEDICARE RAILROAD
GA00381917DMedicaid
GA00381917CMedicaid