Provider Demographics
NPI:1649233412
Name:WILSON, LARA CORBETT (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:CORBETT
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:LOU
Other - Last Name:CORBETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:851 LEONARD FULGHUM BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3787
Mailing Address - Country:US
Mailing Address - Phone:843-884-5133
Mailing Address - Fax:843-849-3343
Practice Address - Street 1:851 LEONARD FULGHUM BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3787
Practice Address - Country:US
Practice Address - Phone:843-884-5133
Practice Address - Fax:843-849-3343
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20495207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT42692Medicaid
SCT42692Medicaid
SCG76192Medicare UPIN