Provider Demographics
NPI:1558496117
Name:WILSON, HENRY B (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1072 X RAY DR STE B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-671-1094
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:13539 REESE BLVD W STE 100
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7961
Practice Address - Country:US
Practice Address - Phone:704-892-4878
Practice Address - Fax:434-384-1074
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101244179174400000X
TN386522086S0122X
NC2022-03010208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1558496117Medicaid
VAH97071Medicare UPIN
VA1558496117Medicaid