Provider Demographics
NPI:1942620257
Name:WILSON, ALEX MARY LOGAN (DO)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:MARY LOGAN
Last Name:WILSON
Suffix:
Gender:F
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-865-2122
Mailing Address - Fax:803-865-1464
Practice Address - Street 1:233 LONGTOWN RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8550
Practice Address - Country:US
Practice Address - Phone:803-865-2122
Practice Address - Fax:803-865-1464
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90103207R00000X
NC201047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine