Provider Demographics
NPI:1275535916
Name:WILCOX, SAM II (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:WILCOX
Suffix:II
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 1:1225 E GARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5115
Mailing Address - Country:US
Mailing Address - Phone:704-865-7416
Mailing Address - Fax:704-865-7232
Practice Address - Street 1:1225 E GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5115
Practice Address - Country:US
Practice Address - Phone:704-865-7416
Practice Address - Fax:704-865-7232
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500314174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCI34311Medicare UPIN