Provider Demographics
NPI:1760518773
Name:WILFONG, W WINSTON (MD)
Entity Type:Individual
Prefix:
First Name:W
Middle Name:WINSTON
Last Name:WILFONG
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:PO BOX 1539
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-1539
Mailing Address - Country:US
Mailing Address - Phone:229-785-2400
Mailing Address - Fax:229-207-2532
Practice Address - Street 1:4 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6783
Practice Address - Country:US
Practice Address - Phone:229-785-2400
Practice Address - Fax:229-207-2532
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028479208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000391036BMedicaid
GA202G701316OtherMEDICARE GROUP PTAN
GA102I342359OtherMEDICARE PTAN
GA2589698966AMedicare ID - Type Unspecified
GA573307OtherBLUE SHIELD
GA000391036AMedicaid
GA102I342359OtherMEDICARE-COLQUITT REGIONAL UROLOGY LLC