Provider Demographics
NPI:1689607566
Name:WILSON, RICHARD HARDING (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HARDING
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 1:1001 HEIFERHORN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-1258
Mailing Address - Country:US
Mailing Address - Phone:706-576-5021
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8839
Practice Address - Country:US
Practice Address - Phone:706-327-5547
Practice Address - Fax:706-323-6821
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA25072208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD41409Medicare UPIN