Provider Demographics
NPI:1174935431
Name:WILSON, SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
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 1:170 MANNING DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-7236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 MANNING DRIVE 1ST FLOOR PHYSICIAN'S OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-5368
Practice Address - Country:US
Practice Address - Phone:919-966-1178
Practice Address - Fax:919-966-7629
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-004662080P0207X, 207RH0003X
MI4301105106390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program