Organization
CARMEN J WILSON MD PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CARMEN J WILSON MD (OWNER)
(866) 779-3937
Entity
Organization
Contact information
Practice address
1760 CANDLER RD, SUITE D, DECATUR, GA 30032-3254
(678) 914-4733
(404) 286-2020
Mailing address
67 HARBOUR LAKE DRIVE, FAYETTEVILLE, GA 30215
(678) 914-4733
(770) 474-4620
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
044609
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000791249C
—
GA
01
—
10064121
AMERIGROUP
GA
01
—
188DGMX
MEDICARE PTAN
GA
01
—
290982
WELL CARE
GA
Enumeration date
06/04/2007
Last updated
02/26/2010
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