Provider Demographics
NPI:1679521298
Name:WILSON, ALVIN T III (DO)
Entity type:Individual
Prefix:
First Name:ALVIN
Middle Name:T
Last Name:WILSON
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2152
Mailing Address - Country:US
Mailing Address - Phone:706-353-7648
Mailing Address - Fax:706-353-7788
Practice Address - Street 1:300 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2152
Practice Address - Country:US
Practice Address - Phone:706-353-7648
Practice Address - Fax:706-353-7788
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE32392Medicare UPIN