Provider Demographics
NPI:1376561415
Name:WILSON, CAROL (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 5TH ST S
Mailing Address - Street 2:DEPT 6590
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4804
Mailing Address - Country:US
Mailing Address - Phone:727-767-7739
Mailing Address - Fax:
Practice Address - Street 1:601 5TH ST S
Practice Address - Street 2:DEPT 6590
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4804
Practice Address - Country:US
Practice Address - Phone:727-767-7739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79468208000000X
NC200700845208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78648OtherBCBS
NC891451EMedicaid
GA125195254AMedicaid
FL265213700Medicaid
FL265213700Medicaid
GA125195254AMedicaid