Provider Demographics
NPI:1982795761
Name:WILSON, DAVID RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RANDALL
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 1:150 GILBREATH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-2827
Mailing Address - Country:US
Mailing Address - Phone:205-274-8198
Mailing Address - Fax:205-274-8197
Practice Address - Street 1:150 GILBREATH DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-2827
Practice Address - Country:US
Practice Address - Phone:205-274-8198
Practice Address - Fax:205-274-8197
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL541387305Medicaid
AL000085127Medicaid
AL541387305Medicaid
AL000085127Medicaid