Provider Demographics
NPI:1356345094
Name:WILSON, LARRY LEE (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-754-9166
Mailing Address - Fax:704-754-2972
Practice Address - Street 1:14 DOCTORS CIR
Practice Address - Street 2:SUITE 5
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4097
Practice Address - Country:US
Practice Address - Phone:910-754-9166
Practice Address - Fax:910-754-2972
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16506207V00000X
NC200601686207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL10281Medicaid
SCL10281Medicaid