Provider Demographics
NPI:1922099746
Name:WILSON, EUGENE WILEY IV (DO)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:WILEY
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 MALLET HILL CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-3126
Mailing Address - Country:US
Mailing Address - Phone:803-509-0456
Mailing Address - Fax:
Practice Address - Street 1:84 MALLET HILL CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-3126
Practice Address - Country:US
Practice Address - Phone:803-509-0456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002999A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology