Provider Demographics
NPI:1427203207
Name:CLAYTON D WILSON MD
Entity Type:Organization
Organization Name:CLAYTON D WILSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-762-0531
Mailing Address - Street 1:1009 N LOCUST AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-2746
Mailing Address - Country:US
Mailing Address - Phone:931-762-0531
Mailing Address - Fax:931-762-0998
Practice Address - Street 1:1009 N LOCUST AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-2746
Practice Address - Country:US
Practice Address - Phone:931-762-0531
Practice Address - Fax:931-762-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD19654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TN30435672Medicare PIN
TNPENDINGMedicaid