Healthcare Provider Details

I. General information

NPI: 1063526507
Provider Name (Legal Business Name): ERIC WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 01/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5440 HILLANDALE DR KAISER PERMANENTE PANOLA MEDICAL CENTER
LITHONIA GA
30058-4865
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-322-2777
  • Fax: 706-549-5981
Mailing address:
  • Phone: 404-364-7070
  • Fax: 706-549-5981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number030694
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: