Healthcare Provider Details

I. General information

NPI: 1780658203
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS OF W GA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DIXIE ST
CARROLLTON GA
30117-3816
US

IV. Provider business mailing address

112 WILSHIRE VILLAGE DR
PEACHTREE CITY GA
30269-3138
US

V. Phone/Fax

Practice location:
  • Phone: 770-838-9333
  • Fax: 770-838-7755
Mailing address:
  • Phone: 770-636-3376
  • Fax: 770-838-7755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH JO WILSON
Title or Position: OWNER/MANAGING DIRECTOR
Credential: MD
Phone: 770-838-9333