Provider Demographics
NPI:1174531313
Name:WILMOT, GEORGE R III (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:R
Last Name:WILMOT
Suffix:III
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 COUNTRY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-6762
Mailing Address - Country:US
Mailing Address - Phone:770-381-6373
Mailing Address - Fax:
Practice Address - Street 1:1841 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4021
Practice Address - Country:US
Practice Address - Phone:404-728-4895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0046082084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG57825001Medicare UPIN