Provider Demographics
NPI:1811186034
Name:WILSON, BRENT A (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 PEACHTREE ST NE
Mailing Address - Street 2:APT 1303
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1245
Mailing Address - Country:US
Mailing Address - Phone:410-533-2000
Mailing Address - Fax:480-287-8015
Practice Address - Street 1:800 PEACHTREE ST NE
Practice Address - Street 2:APT 1303
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1245
Practice Address - Country:US
Practice Address - Phone:410-533-2000
Practice Address - Fax:480-287-8015
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0593502084P0800X
CODR.00534682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60886358Medicaid