Healthcare Provider Details

I. General information

NPI: 1073193009
Provider Name (Legal Business Name): GEORGE GEOFFREY WILSON JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 PEGRAM DR
TUPELO MS
38801-6319
US

IV. Provider business mailing address

440 PEGRAM DR
TUPELO MS
38801-6319
US

V. Phone/Fax

Practice location:
  • Phone: 662-844-5344
  • Fax: 662-841-0407
Mailing address:
  • Phone: 662-844-5344
  • Fax: 662-841-0407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36822
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: