Healthcare Provider Details

I. General information

NPI: 1750910949
Provider Name (Legal Business Name): MARY KATE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SIMPSON ST
GREENVILLE SC
29605-4413
US

IV. Provider business mailing address

300 E MCBEE AVE STE 300
GREENVILLE SC
29601-2899
US

V. Phone/Fax

Practice location:
  • Phone: 864-522-3900
  • Fax: 864-522-3909
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number166739
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number96208
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberME166739
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: