Provider Demographics
NPI:1285894352
Name:WILSON, JEREMIAH J (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2344
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-2344
Mailing Address - Country:US
Mailing Address - Phone:706-922-0600
Mailing Address - Fax:706-922-0604
Practice Address - Street 1:127 TELFAIR ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2590
Practice Address - Country:US
Practice Address - Phone:706-922-0600
Practice Address - Fax:706-922-0604
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066105207Q00000X
SCMD30978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112490AMedicaid
GA202I089774Medicare PIN