Provider Demographics
NPI:1629062211
Name:WILSON, LARRY A (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:A
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:4924 CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-5908
Practice Address - Country:US
Practice Address - Phone:443-461-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD26253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD323511800Medicaid
MD323511800Medicaid
MD340856YWV2Medicare PIN
MD154925ZDDBMedicare PIN
MD154925ZDDB - 149619Medicare PIN