Provider Demographics
NPI:1053513911
Name:CARMEN J WILSON MD PC
Entity type:Organization
Organization Name:CARMEN J WILSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-779-3937
Mailing Address - Street 1:67 HARBOUR LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215
Mailing Address - Country:US
Mailing Address - Phone:678-914-4733
Mailing Address - Fax:770-474-4620
Practice Address - Street 1:1760 CANDLER RD
Practice Address - Street 2:SUITE D
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-3254
Practice Address - Country:US
Practice Address - Phone:678-914-4733
Practice Address - Fax:404-286-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044609207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10064121OtherAMERIGROUP
GA000791249CMedicaid
GA188DGMXOtherMEDICARE PTAN
GA290982OtherWELL CARE
G55002Medicare UPIN
GA18BDGMXMedicare ID - Type Unspecified