Provider Demographics
NPI:1558334284
Name:DAVIS, WILEY MASON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILEY
Middle Name:MASON
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1166
Mailing Address - Fax:704-384-1181
Practice Address - Street 1:11840 SOUTHMORE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4466
Practice Address - Country:US
Practice Address - Phone:704-384-1166
Practice Address - Fax:704-384-1181
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-08-31
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Provider Licenses
StateLicense IDTaxonomies
NC32309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927894Medicaid
NC205801GMedicare PIN
NC8927894Medicaid