Provider Demographics
NPI:1265428445
Name:WILSON, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:755 WALTHER RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8725
Mailing Address - Country:US
Mailing Address - Phone:770-962-0399
Mailing Address - Fax:770-995-0533
Practice Address - Street 1:755 WALTHER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8725
Practice Address - Country:US
Practice Address - Phone:770-962-0399
Practice Address - Fax:770-995-0533
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA39267207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00622993AMedicaid
GA00622993AMedicaid
GA06BDCWNMedicare ID - Type Unspecified