Provider Demographics
NPI:1285291286
Name:WILSON, DARRYEL ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:DARRYEL
Middle Name:ALEXANDER
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 1:2465 WALL ST SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6342
Mailing Address - Country:US
Mailing Address - Phone:770-231-9413
Mailing Address - Fax:
Practice Address - Street 1:14779 BROWN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4127
Practice Address - Country:US
Practice Address - Phone:770-788-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA95240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine