Healthcare Provider Details

I. General information

NPI: 1700872652
Provider Name (Legal Business Name): WILLIAM EARL WILSON SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BISHOP GADSDEN WAY STE 97
CHARLESTON SC
29412-3506
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-406-2362
  • Fax: 843-606-8082
Mailing address:
  • Phone: 843-789-1620
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8168
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: