Provider Demographics
NPI:1962633164
Name:WILSON, LAWRENCE EUGENE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:EUGENE
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:720 WESTVIEW DRIVE SW
Mailing Address - Street 2:HARRIS BLDG., 100-A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:
Practice Address - Street 1:535 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-0104
Practice Address - Country:US
Practice Address - Phone:404-729-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301095126207VC0200X, 2086S0102X
GA66438207VC0200X, 2086S0102X
HI17335207VC0200X, 2086S0102X
CAA1313002086S0102X, 207VC0200X
ORMD190651208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist