Provider Demographics
NPI:1689719890
Name:WILCOXSON, GLEN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:PAUL
Last Name:WILCOXSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 TIMBER WAY
Mailing Address - Street 2:STE 102
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36527
Mailing Address - Country:US
Mailing Address - Phone:251-447-0333
Mailing Address - Fax:251-447-0009
Practice Address - Street 1:1 TIMBER WAY
Practice Address - Street 2:STE 102
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36527
Practice Address - Country:US
Practice Address - Phone:251-447-0333
Practice Address - Fax:251-447-0009
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL5915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P61717Medicare UPIN