Provider Demographics
NPI:1467499061
Name:WILSON, BRETT LAMOND (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:LAMOND
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-8403
Mailing Address - Country:US
Mailing Address - Phone:919-460-0993
Mailing Address - Fax:919-481-3952
Practice Address - Street 1:97 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-8403
Practice Address - Country:US
Practice Address - Phone:919-460-0993
Practice Address - Fax:919-481-3952
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40044208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7988239Medicaid
NC88239OtherBCBS
NC7988239Medicaid