Healthcare Provider Details

I. General information

NPI: 1962633164
Provider Name (Legal Business Name): LAWRENCE EUGENE WILSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 COLISEUM DR
MACON GA
31217-0104
US

IV. Provider business mailing address

720 WESTVIEW DRIVE SW HARRIS BLDG., 100-A
ATLANTA GA
30310
US

V. Phone/Fax

Practice location:
  • Phone: 404-729-4532
  • Fax:
Mailing address:
  • Phone: 404-756-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License Number4301095126
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License Number66438
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License Number17335
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number17335
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberA131300
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License NumberA131300
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number4301095126
License Number StateMI
# 8
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD190651
License Number StateOR
# 9
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number66438
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: