Provider Demographics
NPI:1013079870
Name:WILSON, BEVERLEY DELORIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLEY
Middle Name:DELORIS
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BEVERLEY
Other - Middle Name:DELORIS
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7756
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-7756
Mailing Address - Country:US
Mailing Address - Phone:803-724-7560
Mailing Address - Fax:833-320-1558
Practice Address - Street 1:1 HARBISON WAY STE 221
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3407
Practice Address - Country:US
Practice Address - Phone:803-724-7560
Practice Address - Fax:833-320-1558
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16075208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC160756Medicaid
SC160756Medicaid