Provider Demographics
NPI:1225204480
Name:LEROY A WILSON M D P C
Entity Type:Organization
Organization Name:LEROY A WILSON M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:AUGUSTUS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:404-659-1234
Mailing Address - Street 1:315 BOULEVARD NE
Mailing Address - Street 2:SUITE 316
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312
Mailing Address - Country:US
Mailing Address - Phone:404-659-1234
Mailing Address - Fax:404-659-0640
Practice Address - Street 1:315 BOULEVARD NE
Practice Address - Street 2:SUITE 316
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312
Practice Address - Country:US
Practice Address - Phone:404-659-1234
Practice Address - Fax:404-659-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12594261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center