Basic Information
| Provider Information | |||||||||
| NPI: | 1922301589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | KENNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5059 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528083696 | ||||||||
| FaxNumber: | 2528082022 | ||||||||
| Practice Location | |||||||||
| Address1: | 5059 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528083696 | ||||||||
| FaxNumber: | 2528082022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2010 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101235535 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 2014-02270 | NC | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.