Provider Demographics
NPI:1740220920
Name:WILSON, MITCHELL JAY (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JAY
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:P.O. BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 OLD DALTON ELLIJAY RD
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2029
Practice Address - Country:US
Practice Address - Phone:706-517-2030
Practice Address - Fax:706-517-2076
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA248099221DMedicaid
GA248099221DMedicaid