Provider Demographics
NPI:1922301589
Name:WILSON, EUGENE KENNON III (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:KENNON
Last Name:WILSON
Suffix:III
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 1:5059 HWY 70 W
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4503
Mailing Address - Country:US
Mailing Address - Phone:252-808-3696
Mailing Address - Fax:252-808-2022
Practice Address - Street 1:5059 HWY 70 W
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4503
Practice Address - Country:US
Practice Address - Phone:252-808-3696
Practice Address - Fax:252-808-2022
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235535207Q00000X
NC2014-02270208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine