Provider Demographics
NPI:1598901829
Name:WILSON, LAURIE SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:SUZANNE
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 1:3488 STINSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1655
Mailing Address - Country:US
Mailing Address - Phone:678-588-1253
Mailing Address - Fax:
Practice Address - Street 1:1540 SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9399
Practice Address - Country:US
Practice Address - Phone:304-429-6755
Practice Address - Fax:304-429-0262
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine