Provider Demographics
NPI:1053324293
Name:WILSON, CAROLYN ALICE (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ALICE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 HANCOCK ST
Mailing Address - Street 2:BANGOR VA CLINIC
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-561-3600
Mailing Address - Fax:207-947-1862
Practice Address - Street 1:304 HANCOCK ST
Practice Address - Street 2:BANGOR VA CLINIC
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-561-3600
Practice Address - Fax:207-947-1862
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016114207R00000X
NC120975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine