Basic Information
Provider Information | |||||||||
NPI: | 1598765562 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | DENNIS | ||||||||
MiddleName: | NF | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1718 E 4TH ST | ||||||||
Address2: | SUITE 501 | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282043261 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043439800 | ||||||||
FaxNumber: | 7048877570 | ||||||||
Practice Location | |||||||||
Address1: | 911 W HENDERSON ST | ||||||||
Address2: | SUITE 230 | ||||||||
City: | SALISBURY | ||||||||
State: | NC | ||||||||
PostalCode: | 281442736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046339620 | ||||||||
FaxNumber: | 7046337504 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2005 | ||||||||
LastUpdateDate: | 10/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 38575 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | N38575 | 05 | SC |   | MEDICAID | 8911868 | 05 | NC |   | MEDICAID |