Provider Demographics
NPI:1093100083
Name:WILSON, BENJAMIN ROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ROSS
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1010 PRINCE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5805
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:
Practice Address - Street 1:1010 PRINCE AVE STE 300
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5805
Practice Address - Country:US
Practice Address - Phone:706-425-1470
Practice Address - Fax:706-425-1471
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92070207VX0201X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program