MEDICARE: GREGORY J WILMOTH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	9900389	NC
2	207ND0101X	MOHS-Micrographic Surgery Physician	9900389	NC

General Provider Information

NPI Number	:	1013954742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY J WILMOTH M.D.

Provider Business Mailing Address
First Line	:	4201 LAKE BOONE TRL
Second Line	:	SUITE 200
City	:	RALEIGH
State	:	NC
Zip	:	27607-7511
Country	:	US
Telephone Number	:	919-782-2152
Fax Number	:	919-782-7929

Provider Business Practice Location Address
First Line	:	4201 LAKE BOONE TRL
Second Line	:	SUITE 200
City	:	RALEIGH
State	:	NC
Zip	:	27607-7511
Country	:	US
Telephone Number	:	919-782-2152
Fax Number	:	919-782-7929

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	10/05/2020

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