Healthcare Provider Details

I. General information

NPI: 1508859448
Provider Name (Legal Business Name): DARYL CARSON WILEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 FLUKER ST
THOMSON GA
30824-2108
US

IV. Provider business mailing address

315 FLUKER ST
THOMSON GA
30824-2108
US

V. Phone/Fax

Practice location:
  • Phone: 706-595-1090
  • Fax: 706-595-6010
Mailing address:
  • Phone: 706-595-1090
  • Fax: 706-595-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number032327
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: