Provider Demographics
NPI:1508859448
Name:WILEY, DARYL CARSON (MD)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:CARSON
Last Name:WILEY
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 1:315 FLUKER ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-2108
Mailing Address - Country:US
Mailing Address - Phone:706-595-1090
Mailing Address - Fax:706-595-6010
Practice Address - Street 1:315 FLUKER ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2108
Practice Address - Country:US
Practice Address - Phone:706-595-1090
Practice Address - Fax:706-595-6010
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000442604EMedicaid
GAGRP4411Medicare ID - Type Unspecified
GAE81476Medicare UPIN