Provider Demographics
NPI:1699852814
Name:WILSON, KIMBERLEY ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ELLIOTT
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:GAIL
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2001 PEACHTREE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1476
Mailing Address - Country:US
Mailing Address - Phone:404-351-2551
Mailing Address - Fax:404-351-9238
Practice Address - Street 1:2001 PEACHTREE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1476
Practice Address - Country:US
Practice Address - Phone:404-351-2551
Practice Address - Fax:404-351-9238
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031363207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F42885Medicare UPIN
GA66BBBB0Medicare ID - Type Unspecified