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NPI Code Detail

MEDICARE: LARA CORBETT WILSON MD

MEDICARE: LARA CORBETT WILSON MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207V00000XObstetrics & Gynecology Physician20495SC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1649233412
Entity Type Code : Individual
Provider Name (Legal Business Name) : LARA CORBETT WILSON MD
Provider Business Mailing Address
First Line : 851 LEONARD FULGHUM BLVD
Second Line : SUITE 201
City : MT PLEASANT
State : SC
Zip : 29464-3787
Country : US
Telephone Number : 843-884-5133
Fax Number : 843-849-3343
Provider Business Practice Location Address
First Line : 851 LEONARD FULGHUM BLVD
Second Line : SUITE 201
City : MT PLEASANT
State : SC
Zip : 29464-3787
Country : US
Telephone Number : 843-884-5133
Fax Number : 843-849-3343
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/11/2006
Last Update Date : 08/15/2014

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Directions to “ LARA CORBETT WILSON MD” Practice Location

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