Provider Demographics
NPI:1003132754
Name:WILSON, MARK DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 12TH ST W
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3923
Mailing Address - Country:US
Mailing Address - Phone:229-396-5335
Mailing Address - Fax:229-396-5330
Practice Address - Street 1:215 12TH ST W
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3923
Practice Address - Country:US
Practice Address - Phone:229-396-5335
Practice Address - Fax:229-396-5330
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069737208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA69737OtherLICENSE
GAFW3838729OtherDEA