Provider Demographics
NPI:1972563013
Name:WILSON, SHARMELL O (MD)
Entity Type:Individual
Prefix:DR
First Name:SHARMELL
Middle Name:O
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4922
Mailing Address - Country:US
Mailing Address - Phone:919-488-0015
Mailing Address - Fax:919-277-0066
Practice Address - Street 1:11130 CAPITAL BLVD
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4513
Practice Address - Country:US
Practice Address - Phone:919-488-4094
Practice Address - Fax:919-488-4096
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201202208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89132KKMedicaid
NC89132KKMedicaid