Provider Demographics
NPI:1639180193
Name:WILSON, ROY C (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:C
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:2025 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4590
Practice Address - Country:US
Practice Address - Phone:314-330-5348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361084112084P0800X
MOR2F262084P0800X
SC516142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108411OtherBLUE SHIELD