Provider Demographics
NPI:1336633569
Name:WILSON, LYTANI (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:LYTANI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 IRVIN CT STE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1780
Mailing Address - Country:US
Mailing Address - Phone:404-778-0641
Mailing Address - Fax:
Practice Address - Street 1:505 IRVIN CT STE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1780
Practice Address - Country:US
Practice Address - Phone:404-778-0641
Practice Address - Fax:404-299-7499
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine