Provider Demographics
NPI:1457483869
Name:MARTHA L WILSON MD PA
Entity Type:Organization
Organization Name:MARTHA L WILSON MD PA
Other - Org Name:MARTHA L WILSON MD PA PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-238-9902
Mailing Address - Street 1:104 E STUART DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2119
Mailing Address - Country:US
Mailing Address - Phone:276-238-9902
Mailing Address - Fax:276-238-9907
Practice Address - Street 1:104 E STUART DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2119
Practice Address - Country:US
Practice Address - Phone:276-238-9902
Practice Address - Fax:276-238-9907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49D1001134207N00000X, 207ND0101X
207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49D1001134OtherCLIA NUMBER
VA49D1001134OtherCLIA NUMBER