Provider Demographics
NPI:1083602130
Name:WILSON, PETER S (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
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 1:4704 WHITESBURG DR SW STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-1681
Mailing Address - Country:US
Mailing Address - Phone:256-533-7064
Mailing Address - Fax:256-704-0115
Practice Address - Street 1:4704 WHITESBURG DR SW STE 200
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802
Practice Address - Country:US
Practice Address - Phone:256-880-4510
Practice Address - Fax:256-880-4512
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.15425208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000070292Medicaid
AL020040119OtherRR MEDICARE
AL000070292Medicare ID - Type Unspecified
AL020040119OtherRR MEDICARE