Healthcare Provider Details

I. General information

NPI: 1457483869
Provider Name (Legal Business Name): MARTHA L WILSON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E STUART DR
GALAX VA
24333-2119
US

IV. Provider business mailing address

104 E STUART DR
GALAX VA
24333-2119
US

V. Phone/Fax

Practice location:
  • Phone: 276-238-9902
  • Fax: 276-238-9907
Mailing address:
  • Phone: 276-238-9902
  • Fax: 276-238-9907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number49D1001134
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number49D1001134
License Number StateVA

VIII. Authorized Official

Name: DR. MARTHA L WILSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 276-238-9902