Provider Demographics
NPI:1063859361
Name:WILSON, COREY STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:STEPHEN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:980-488-4900
Mailing Address - Fax:980-488-4905
Practice Address - Street 1:10905 PROVIDENCE RD W, STE G200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1538
Practice Address - Country:US
Practice Address - Phone:980-488-4900
Practice Address - Fax:980-488-4905
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-00423208M00000X
FLME127654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017818500Medicaid
FLIQ045ZMedicare PIN