Provider Demographics
NPI:1427041284
Name:WILSON, DAVID MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:D.
Other - Middle Name:MARK
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-1599
Mailing Address - Country:US
Mailing Address - Phone:843-347-7144
Mailing Address - Fax:843-347-7331
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-347-7144
Practice Address - Fax:843-347-7331
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15323207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC153238Medicaid
SCF238713797Medicare ID - Type Unspecified
SC153238Medicaid