Provider Demographics
NPI:1336271733
Name:WILSON, MARTHA L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:L
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 1:104 E STUART DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2119
Mailing Address - Country:US
Mailing Address - Phone:276-238-9902
Mailing Address - Fax:276-238-9907
Practice Address - Street 1:104 E STUART DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2119
Practice Address - Country:US
Practice Address - Phone:276-238-9902
Practice Address - Fax:276-238-9907
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230418207N00000X, 207ND0101X, 207NP0225X, 207NS0135X
FLME0042356207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA070017626OtherRAILROAD MEDICARE
VA463187OtherANTHEM BCBS (TRIGON)
VAAW9811010OtherDEA NUMBER
VA070000357Medicare ID - Type UnspecifiedMEDICARE
VA070017626OtherRAILROAD MEDICARE