Provider Demographics
NPI:1770660060
Name:WILSON, ADDISON GRAVES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ADDISON
Middle Name:GRAVES
Last Name:WILSON
Suffix:JR
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 1:1 PINCKNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6122
Mailing Address - Country:US
Mailing Address - Phone:843-228-5455
Mailing Address - Fax:
Practice Address - Street 1:1840 COVE RD
Practice Address - Street 2:LOGSU-2 MEDICAL DEPARTMENT
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23521-2910
Practice Address - Country:US
Practice Address - Phone:757-462-3025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97126207QA0505X
VA0101242561208D00000X
SCMD40144207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice