Provider Demographics
NPI:1821529348
Name:WILSON, KELSEY DERRICK (MD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:DERRICK
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:D
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:213 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4019
Mailing Address - Country:US
Mailing Address - Phone:864-272-3300
Mailing Address - Fax:864-272-3311
Practice Address - Street 1:3B CLEVELAND CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2414
Practice Address - Country:US
Practice Address - Phone:864-272-3300
Practice Address - Fax:864-272-3311
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85751207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology