Provider Demographics
NPI:1669491221
Name:WILSON, KAFI (MD)
Entity Type:Individual
Prefix:
First Name:KAFI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAFI
Other - Middle Name:WILSON
Other - Last Name:TERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:1035 RED BUD RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701
Practice Address - Country:US
Practice Address - Phone:706-879-4776
Practice Address - Fax:706-879-4781
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075716207R00000X
WI49039-020208M00000X
GA75716208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003178325CMedicaid
GA003178325BMedicaid