Provider Demographics
NPI:1346221561
Name:WILSON, DENNIS ALONZO (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:ALONZO
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:PO BOX 23094
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-3094
Mailing Address - Country:US
Mailing Address - Phone:803-846-3596
Mailing Address - Fax:803-736-7658
Practice Address - Street 1:602 AIRPORT RD STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2617
Practice Address - Country:US
Practice Address - Phone:864-234-7952
Practice Address - Fax:864-234-7985
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15193208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC151925Medicaid
SC151925Medicaid
SCF67554Medicare UPIN