Provider Demographics
NPI:1174589345
Name:WILSON DERMATOLOGY CLINIC PA
Entity type:Organization
Organization Name:WILSON DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:252-291-5600
Mailing Address - Street 1:2874 WARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-1761
Mailing Address - Country:US
Mailing Address - Phone:252-291-5600
Mailing Address - Fax:252-291-6935
Practice Address - Street 1:2874 WARD BLVD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-1761
Practice Address - Country:US
Practice Address - Phone:252-291-5600
Practice Address - Fax:252-291-6935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH32350Medicare UPIN
NC2401180Medicare ID - Type UnspecifiedDR. DAVID CORBETT