Provider Demographics
NPI:1275573388
Name:WILSON, BRYANT W (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:W
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:95 COLLIER RD NW
Mailing Address - Street 2:SUITE 6015
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1796
Mailing Address - Country:US
Mailing Address - Phone:404-351-5959
Mailing Address - Fax:404-351-8526
Practice Address - Street 1:95 COLLIER RD NW
Practice Address - Street 2:SUITE 6015
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1796
Practice Address - Country:US
Practice Address - Phone:404-351-5959
Practice Address - Fax:404-351-8526
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA029824208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00441361BMedicaid
GAD41410Medicare UPIN
GA02BDBKTMedicare ID - Type Unspecified