Provider Demographics
NPI:1962723817
Name:WILSON, RICHARD IAN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:IAN
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 7200
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0200
Mailing Address - Country:US
Mailing Address - Phone:252-937-0200
Mailing Address - Fax:252-451-0056
Practice Address - Street 1:91 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-9590
Practice Address - Country:US
Practice Address - Phone:252-451-3200
Practice Address - Fax:252-937-3107
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD465876207Q00000X
NC2016-01141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine