Provider Demographics
NPI:1801830740
Name:WILSON, LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 E KIEHL AVE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3040
Mailing Address - Country:US
Mailing Address - Phone:501-835-0703
Mailing Address - Fax:501-834-6249
Practice Address - Street 1:1308 E KIEHL AVE
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-3040
Practice Address - Country:US
Practice Address - Phone:501-835-0703
Practice Address - Fax:501-834-6249
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4416208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR7226719OtherAETNA
AR157741001Medicaid
AR5N239OtherBLUE CROSS
AR05070026700OtherQUALCHIOICE
AR157741001Medicaid
AR5N239Medicare PIN