Provider Demographics
NPI:1467549170
Name:WILSON, TERRI M (MD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-1660
Mailing Address - Country:US
Mailing Address - Phone:770-358-1961
Mailing Address - Fax:770-358-9233
Practice Address - Street 1:101 HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1660
Practice Address - Country:US
Practice Address - Phone:770-358-1961
Practice Address - Fax:770-358-9233
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC16001OtherRAILROAD MEDICARE
GA000506514AMedicaid
GA000506514AMedicaid
GA08BDFKTMedicare PIN
GA08BDFKTMedicare ID - Type Unspecified