1538438452 NPI number — MR. LEWIS CODY BUCK WILSON AA CERTIFIED

Table of content: MR. LEWIS CODY BUCK WILSON AA CERTIFIED (NPI 1538438452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538438452 NPI number — MR. LEWIS CODY BUCK WILSON AA CERTIFIED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
LEWIS
Provider Middle Name:
CODY BUCK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AA CERTIFIED
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538438452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1984 PEACHTREE RD NW
Provider Second Line Business Mailing Address:
515
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-5219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-351-1745
Provider Business Mailing Address Fax Number:
404-351-7121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1984 PEACHTREE RD NW
Provider Second Line Business Practice Location Address:
515
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30309-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-351-1745
Provider Business Practice Location Address Fax Number:
404-351-7121
Provider Enumeration Date:
12/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367H00000X , with the licence number:  2327 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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