Healthcare Provider Details

I. General information

NPI: 1629062211
Provider Name (Legal Business Name): LARRY A WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4924 CAMPBELL BLVD
BALTIMORE MD
21236-5908
US

IV. Provider business mailing address

PO BOX 759047
BALTIMORE MD
21275-9047
US

V. Phone/Fax

Practice location:
  • Phone: 443-461-1997
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD26253
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: