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General NPI Number Information
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NPI Number | 1134121221
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Entity Type | Individual
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Provider Name | LARRY T WILSON MD
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Gender | Male
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Dates
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Enumeration Date | 06/02/2005
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Last Update Date | 08/28/2009
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Provider Practice Location Address
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Address Line | 701 S MORGAN AVE
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City | ANDREWS
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State | SC
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Zip | 29510
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Country | US
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Telephone | 843-264-5253
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Fax | 843-264-5970
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Provider Business Mailing Address
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Address Line | 1075 N FRASER ST
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City | GEORGETOWN
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State | SC
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Zip | 29440
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Country | US
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Telephone | 843-527-4442
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Fax | 843-527-4027
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD35689
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101231693
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | TL32077
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License Number State | SC
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