Provider Demographics
NPI:1568455244
Name:WILSON, EARL KEITH (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:KEITH
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 1:3183 W STATE ST
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1712
Mailing Address - Country:US
Mailing Address - Phone:423-764-0987
Mailing Address - Fax:423-652-2512
Practice Address - Street 1:3183 W STATE ST
Practice Address - Street 2:SUITE 1201
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1712
Practice Address - Country:US
Practice Address - Phone:423-764-0987
Practice Address - Fax:423-652-2512
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN130902084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3183937Medicaid
KY7100018090Medicaid
TN69855Medicaid
VA006193676Medicaid
VA010363276Medicaid
VA010363276Medicaid
KY7100018090Medicaid
TN69855Medicaid
VAC04526Medicare PIN
VAC04525Medicare PIN
TNP00447994Medicare PIN
TN103I132902Medicare PIN
TN3183937Medicare PIN
VA130000539Medicare PIN
VA130000538Medicare PIN