Provider Demographics
NPI:1801941018
Name:DRAKE, WILTON RODWELL JR (MD)
Entity type:Individual
Prefix:
First Name:WILTON
Middle Name:RODWELL
Last Name:DRAKE
Suffix:JR
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 1:101 HUNT ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-3414
Mailing Address - Country:US
Mailing Address - Phone:919-693-2141
Mailing Address - Fax:919-693-8517
Practice Address - Street 1:101 HUNT ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3414
Practice Address - Country:US
Practice Address - Phone:919-693-2141
Practice Address - Fax:919-693-8517
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17950208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C83569Medicare UPIN