Provider Demographics
NPI:1700872652
Name:WILSON, WILLIAM EARL SR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:EARL
Last Name:WILSON
Suffix:SR
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1 BISHOP GADSDEN WAY STE 97
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3506
Practice Address - Country:US
Practice Address - Phone:843-406-2362
Practice Address - Fax:843-606-8082
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00754343OtherRAILROAD MC ID- RSFPN
SCD906839223Medicare PIN
SCD906835858Medicare UPIN
SC1093732869Medicare PIN
SCP00754343OtherRAILROAD MC ID- RSFPN
SC1497874424Medicare PIN
SCD906837197Medicare UPIN
SC081681Medicaid