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NPI Code Detail

MEDICARE: MITCHELL JAY WILSON M.D.

MEDICARE: MITCHELL JAY WILSON 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
1207R00000XInternal Medicine Physician061188GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1740220920
Entity Type Code : Individual
Provider Name (Legal Business Name) : MITCHELL JAY WILSON M.D.
Provider Business Mailing Address
First Line : P.O. BOX 12938
Second Line : C/O CLINIC MANAGEMENT
City : CALHOUN
State : GA
Zip : 30703
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 707 OLD DALTON ELLIJAY RD
Second Line :
City : CHATSWORTH
State : GA
Zip : 30705-2029
Country : US
Telephone Number : 706-517-2030
Fax Number : 706-517-2076
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/07/2006
Last Update Date : 12/19/2018

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