Provider Demographics
NPI:1083686430
Name:WILSON, WILEY (DO)
Entity type:Individual
Prefix:DR
First Name:WILEY
Middle Name:
Last Name:WILSON
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 1:176 LAKEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-5318
Mailing Address - Country:US
Mailing Address - Phone:229-322-0570
Mailing Address - Fax:229-271-7504
Practice Address - Street 1:176 LAKEVIEW CIR
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-5318
Practice Address - Country:US
Practice Address - Phone:229-322-0570
Practice Address - Fax:229-271-7504
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036633208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA795339666AMedicaid
GA511I080722Medicare PIN