Provider Demographics
NPI:1386821007
Name:BLACK, WILEY S (MD)
Entity Type:Individual
Prefix:
First Name:WILEY
Middle Name:S
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2626 PARKER TRL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1800
Mailing Address - Country:US
Mailing Address - Phone:770-532-8608
Mailing Address - Fax:770-718-1964
Practice Address - Street 1:2626 PARKER TRL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-1800
Practice Address - Country:US
Practice Address - Phone:770-532-8608
Practice Address - Fax:770-718-1964
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA009767208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery