Provider Demographics
NPI:1134121221
Name:WILSON, LARRY T (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:T
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 1:1075 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440
Mailing Address - Country:US
Mailing Address - Phone:843-527-4442
Mailing Address - Fax:843-527-4027
Practice Address - Street 1:701 S MORGAN AVE
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:SC
Practice Address - Zip Code:29510
Practice Address - Country:US
Practice Address - Phone:843-264-5253
Practice Address - Fax:843-264-5970
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD35689207Q00000X
VA0101231693207Q00000X
SCTL32077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5642205Medicaid
VA019402F66Medicare PIN
TN3025707Medicare PIN
VA080008025Medicare ID - Type Unspecified
VA5642205Medicaid
TN3872000Medicare PIN